NCC223322_FRO Submitted_20220922

PLAN REVIEW/FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNTY CODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION AND SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres as covered by the Ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Catawba County
Utilities and Engineering Department. (Please type or print, and if question is not applicable, please N/A in the blank)
PART A
1. 7ob Name [Neill Grading Borrow Pit East
2. PIN or 911 Address F3722-14-44-5882
3. Purpose of development (residential, commercial, industrial, institutional,ete.) borrow for single project
4. Approximate soil disturbance date asap
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.65
6. Has an erosion and sedimentation control been filed? r'. Yes F No D? Attached
7. If you have an Erosion Control billing account, would you like this to be billed? F- Yes F_ No
Account Number
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Clay Neill E-mail address [e-mail]
Telephone F 28-324-6774 Cell # 1828-244-62-65 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name Bill Properties Telephone F828-3�24-6774.Fax # F828-324-9632
Current Mailing Address 1130 Box 3916
City Hickory
Current Street Address 13050 1 st Ave Ct 5E
State NC Zip 28603
City Hickory State NC Zip 2860
10. Deed Boole No. 3058 Page No. 5so
�.
PART B
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a compreh,
of all responsible parties on attached sheet):
Name Neill Grading and Construction Co. Inc E-mail address [e-mail]
Current Mailing Address IPO Sox 3916
State NC Zip 2860?
City Hi
ckory -

Current Street Address 130501 st Ave Ct SE
City Hickory State INC Zip 28602
Telephone [phone] Fax # [phone]
2. (a) If the financially responsible patty is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name E-mail address
Current Mailing Address
City
Current Street Address
State
City State
Zip
Telephone Fax #
2. (b) If the financially responsible patty is a Partnership or other person engaging in business under 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:
Name E-mail address
Current Mailing Address
City State Zip
Current Street Address
City State Zip
F_
Telephone Fax #
The above information is true and correct to the best of any knowledge and belief and was provided by me under oath ("Phis 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 connected information should there be any change in the information provided herein.
C.I I f V-e-D
e or Pr' W.
me Title of Authority
G -aZ
Signs Date
I, 2) Lk Ciy_ � ('� i i �0; __ , a+ Notary Public of the County of State of North
Carolina, hereby certify that —a . 0 lc.,.\ZVI� r '! . I [ appeared personally before me this day and being duly
sworn acknowledge that the above form s executed by him.
Witness my hand and notary seal, this �- lt- day of Sep �e oy,6✓
Seal SUSAN J WILSON Uj
Notary Public Notary, _ Sws�.�-- r SC —
North Carolina My Comrmssion expires09 C 2- ,3cA!;
Catawba County