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
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