NCC222545_FRO Submitted_20220715

No person may initiate any land -disturbing activity on one or more uonao as covered bythe Act before this
fnnn and on acceptable enzakmn and sedimentation control plan have been completed and approved by
the Land Quality 3m±ion, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question ianot applicable orthe e-mail and/
orfax information unavailable, place N/A inthe b|ank.)
Part A. ,°°^ Mallard Creek Church o^" Shared Use Path
1. Project Nam
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2. Location ofIan d-di�ur�ngao�vdy CountyMecklenburg = city Charlotte
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Highway/Street Latitude ~~'~'~' Longitude ~~''`^~~
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3. Approximate date land -disturbing activity will commence: °' ''^�""�^�
4. Purpose ofdevelopment (nsuidentiai oommeruia|, industrial, institutional, etc.): Installation orShared Use Path
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5. Total acreage d�durbodoruncovered (including o��odebornmvand waste ansoa):"-'4
0. Amount of fee enclosed: $ ' °1�5^°" OO
The application fee of $100.00 per acre
(rounded uptothe next acre) is assessed without aceiling amount (Example: 8.10 ac = $AOO.OU).
7. Has nnerosion and sediment control plan been fi�� filed? Yee^NoEno|ouad________.
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Natalie King E-mail Address D@[e-mail]@Ch8[lOf[8OC.g0V
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Telephone `^°" -`°"- "°"` Cell # Fax#
8. Lmndownel of Record (attach accompanied page to list additional owners):
City of Charlotte
Name
600 East Fourth Street
Current Mailing Address
Charlotte NC 28202
City State Zip
Telephone Fax Number
600 East Fourth Street
Current Street Address
Charlotte NC 28202
City
10. Deed Book No. Page No. — Provide a copy of the most current deed.
Port B.
1. Compal or finnbA who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the companyorfirm isasole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
City of Charlotte
600East Fourth Street
Current Mailing Address
Charlotte 0C 28202
City State Zip
Fax Number
E-mail Address

2. (a) If the Financially Responsible Party is not a resident of North Cmno|ima, give name and street eddn*ae
of the designated North Carolina Agent:
Current Mailing Address
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(b) If the Financially Responsible Party is o Partnership or other person engaging in business under an
assumed noma, 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip C ity
ZTTURIN,�0
State Zip
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 F|nenc|o|k/ Responsible Person Jon individual
or his 8ftO[n8y-in-fact, Or if not an individual, by an 0f5S8[, director, p8rtD8r. Or registered agent with
the authority to execute instruments for the Financially Responsible Person). | o0nem to provide
C0rn8Ct8d information should there beany change in the information provided herein.
Natalie King
&
Project Manager - M�� +wnfharloY7c.
Type or print name Title
(7- q , 4 -n.( I/
OfIr
Ca- a Notary Public of the County of
State of North Carolina, hereby certify that appeaIr
personally before me this day and being duly sworn acknowled d that the above form was
executed by him. A
Witness my hapq
Notary
'04 My commission expire
LIC