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HomeMy WebLinkAboutNCC222398_FRO Submitted_20220714No person may initiate any land -disturbing activity on one or more acres as covered by the 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 address or phone number is unavailable, place N/A in the blank.) Fart A. 1. Project Name Mitchell Manor for Erosion Control Permit Lots 14, 15, & 17 2. Location of land -disturbing activity: County Harnett City or Township Angler Highway/Street Mitchell Manor Drive 35.4507-78.7119 LatltUde(decimal degrees)______ LOngltUde(decimal degrees) 3. Approximate date land -disturbing activity will commence: July 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .84 6. Amount of fee enclosed: $ 200.00 _�. The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Bryant Lockamy E-mail Address southerntouchhomesllc@gmail.com Phone: Office # 91 9-524-3354 Mobile # 919-524-3354 9 Landowner(s) of Record (attach accompanied page to list additional owners): Southern Touch Homes, Inc. 919-524-3354 Name Phone: Office # P® Box 2135 1843 Maybry Road Current Mailing Address Current Street Address Angier NC 27501 Angier NC 27501 City State Zip City State Zip 4151, 4138, 4138 2040,0684,0684 10. Deed Book No. Page No. Provide a copy of the most current deed. 919-524-3354 Mobile # 1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). Southern Touch Homes, Inc Company Name ISO Box 2135 Current Mailing Address Angler NC 27501 City State Zip Phone: Office # 919-524-3354 SoutherntouchhomesllC@gmail.com E-mail Address Angier NC 27501 Current Street Address Angier NC 27501 City State Zip Mobile # 919-524-3354 Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control plan and to conduct the anticipated land disturbing activity. 2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State business registry, give name and street address of the Registered Agent: Name of Registered Agent Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina agent who is registered on the NC Secretary of State business registry: Name of Registered Agent Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (c) If the Financially Responsible Party is engaging in business under an assumed name, give name under which the company is Doing Business As. If the Financially Responsible Party is an individual, General Partnership, or other company not registered and doing business under an assumed name, attach a copy of the Certificate of Assumed Name. Company DBA Name 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(s) 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 Party). I agree to provide corrected information should there be any change in the information provided herein. Bryant Lockamy Type or print name Sign a'ture President Title or Authority Date IV 1, � 1°v,rus f, L. ------_ a Notary Public of the County of C o e . + State of North Carolina, hereby certify that (_ma`s before me this day and being duly sworn acknowl dged that the a o e form was executed uted by h m/fiereared y Witness my hand and notarial seal, this _ _day of 7p i�-)e �p e� l+ - Notary �OTARt- cp: ate, = My commission expires�� i�_�