NCC222266_FRO Submitted_20220620

No person may initiate any land -disturbing activity onone or more acres as covered bythe Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/4 in the blank.)
Part A. Davidson��Uf� �f[�pf�� [ |DOO�V�[���1� �RU�/�
1� Project Name�� '" South Street °"`^~�"~""�^"~ Improvements Project
Mecklenburg_ �� �� '/�
2. Location of|and'diutudbing activity: County','��<�mf��uU[(J City orTownahi ���������so[]
,_~��°~����=��~ q�»�Qv/1'1 O"�j �Ao�0v��� ��nUV
Highway/Street Latitude =" �� -'-' ° '" Longitud `/v ~�� `'v � »«
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3. Approximate date land -disturbing activity will commenoe:/ ^ '| 1 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.)-. Utility Charlotte Water
�
5. ��|���d����mun��r��ndudi����bomwa�w�ea��:�^�4�� ���wu
S. Amount offee enclosed: 1���� The application fee of$65.00per acre (rounded
uptothe next acre) ioassessed without aceiling amount (Examp|e:uQ-aovaapplication fee ie$585).
7. Has enerosion and sediment control plan been filed? Yes No ��Enu|oeed ��
8. Person tocontact should erosion and sediment control issues arise during land -disturbing activity:
Nam S~~� E-mail Address f^� �� Scott STepHeN.aCOTT@C|.CHARLOTTE. NC. US
K���_�� ��_��� �� y�i& NJi8
�eu �� �� �^�e�� /�/�� *�/x�
Te|ephon CoU# Fax#
Q. Landowner(s) of Record (attach accompanied page to list additional owners):
See Table 1:List o/Easement Property Owners
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide ocopy ofthe most current deed.
PartB.
1Company(ieo) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or film isasole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Charlotte f+ Water '|
��' /��/������ v v����
Name E-mail Address
����� Brookshire
Blvd ���O� Brookshire
Blvd
~� /vu ��[[�[)r��v/���� ��/�u `/ /uw ���[)��/��//�[�� ��/\/�
Current Mailing Address
Charlotte, NC 28216
City State Zip
��[l�������� /���
/w~r w��m ou��u
Te|ephon
Current Street Address
Charlotte, y��� �����
`�//��/�»�u^, /n^� ���/�
City State Zip
kJ/�
Fax /�/�x

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name
N/A
Current Mailing Address
N/A
City
Telephone N/A
State Zip
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
N/A N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
Telephone N/A
E-mail Address
N/A
Current Street Address
N/A
State Zip City State Zip
Fax Number N/A
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Joseph C. Wilson
Tye r print na e
w�
Sign re
-----------------------------------------------------
Chief Engineer
Title or Authority
Date
1
I, a Notary Public of the County of tLl
State of North Carolina, hereby certify that 'dV V�J11`� appea
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of �DNSO_6'C 20 2-1
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I MPS'%,�
s CO No
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