NCC223250_FRO Submitted_20220921

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Twin Lakes Lot 45
1. Project Name
2. Location of land -disturbing activity: County U nlon City or Township Matthews
Highway/Street 510 Sugar Maple Ln Latitude 35.02200354729623 Longitude-80.70283801298977
3. Approximate date land -disturbing activity will commence: 5/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Resldental
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '59
6. Amount of fee enclosed: $ $100 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Justin & Hillary Lattanzio E-mail [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Justin & Hillary Lattanzio 707-495-4959
Name Telephone Fax Number
510 Sugar Maple Lane 510 Sugar Maple Lane
Current Mailing Address Current Street Address
Matthews, NC 28104 Matthews, NC 28104
City State Zip City State Zip
10. Deed Book No. 8347 Page No. 0859 Provide a copy of the most current deed.
Part B.
1. Company(ies) 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 firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Justin & Hillary Lattanzio [e-mail]
Name E-mail Address
5677 Eastlake Dr. 5677 Eastlake Dr.
Current Mailing Address Current Street Address
Santa Rosa, CA 95409 Santa Rosa, CA 95409
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
IY _
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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:
Nla
Name of Registered Agent
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
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 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.
Justin & Hillary Lattanzio
Owners
Type or print name Title or Authorit
W
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Signature Date'
M
a Notary Public of the County of
State of North lina, hereby certify that appeared
personally before m is day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, f4s day of 20

CALIFORNIA ALL-PURPOSE ACKNOWLEDGEMENT
A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed
the document, to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of Sonoma
On 2Z , before me,
personally appeared
who proved to me on the basis of satisfactory evidence to be the persons) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same
in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument
the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of State of California t at e foregoing
paragraph is true and correct. ��
K. ANDERSC)N
, = y COMM. It 2324874
NOTARY PUBLIC - CALIFORNIA WITNESS my
SONClMA COUNTY 0
At1Fun CONIP,I. LKPIKS [vjAI?,17 2 "
SIGNA
PLACE NOTARY SEAL ABOVE
- ......... .......................................................
Though the information below is not required by law, it may prove valuable to
lyi p so reng on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of attached document
Title or type of document:
Document Date:
Number of Pages:
Signer(s) Other than Named Above: