NCC221638_FRO Submitted_20220426

APPLICATION FOR PERMIT FOR A Fite #
LAND DISTURBING ACTIVITY
Under the conditions set forth by LD Fee Review Fee
The New Hanover County
Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
Engineering Department
Applicant or Applicant's Agent: Khalid Saleh
Mailing Address: 3811 Cottonwood Drive Telephone Number: 919-599-0301 Fax Number:
Durham, NC 27705 Email Address: [e-mail]
Total Acres of Land Disturbance: 1.39 Purpose of Development: New commercial construction
Description of Land Disturbance: Demo all existing structures, etc. (in phases) and prepare site for new construction of convience store wl fuel pumps_
Address of Land Disturbance _ 7650 Market Street Latitude: 34.283682 Longitude: _-77. 8017970
STATEMENT OF FINANCIAL RESPONSIBILITY
Land owner(s) of record: Person or firm(s) financially responsible for the
land disturbing activity. If not a North Carolina
resident, you MUST have a N.C. agent. (List Below)
Name: Ann S Downing Name: Khalid aleh
Address: 8044 Bald Eaale Lane Address: 3811 Cottonwood Drive
City/State: Wilmington, NC City/State: Durham, NC
Zip Code: 28405-9303 Zip Code: 27705 _
Telephone Number: 910-520-3133 Telephone Number: 919-599-0301
Email: [e-mail] FaxNumber Email: [e-mail] FaxNumber:
Location of deed(s) or instrument(s): County: New Hanover County Book:1214 & 1s4s Page: 447 & 13sa
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director, partner, attorney -in -
fact, or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
provide corrected information should there be any change in the information provided herein.
_ 7
Date: Name Khalid Saleh Title .
Signature
1, _11a4,&--<� A1 l a Notary Public of the County of _ ► I r' ` State of
North Carolina, herehy certify that hA G,14- � _ appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my and and n seal, this J.S7 , day of � .�� �a�Q� , 20 Z O
Notary My commission expires / 0 f ) 9 /Z-'D Ltd
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Permission to;Lr on Land
I certify that I sm authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the land in question in conueg4on related to this permit application.
Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION