NCC223360_FRO Submitted_20220926

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Neumaier House
2. Location of land -disturbing activity: County Henderson City or Township Mills River
Highway/Street 1020 Tole Allison Road Latitude(dedmai degrees) 35.3529 Long itudeoeGnial degrees) -82.5937
3. Approximate date land -disturbing activity will commence: Upon Approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.65 AC
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 Todd Brinkman E-mail Address [e-mail]
Phone: Office # 828-674-2683 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
THE ERVIN JOHN NEUMAIER, III REVOCABLE TRUST 630-818-6996 630-818-6996
Name Phone: Office # Mobile #
300 STATE STREET APT. 256 300 STATE STREET APT. 256
Current Mailing Address Current Street Address
KNOXVILLE, TN 37902 KNOXVILLE, TN 37902
City State Zip City State Zip
10. Deed Book No. 3925 Page No, 418 Provide a copy of the most current deed.

Part B.
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).
THE ERVIN JOHN NEUMAIER, III REVOCABLE TRUST
Company Name
300 STATE STREET APT. 256
[e-mail]
E-mail Address
300 STATE STREET APT. 256
Current Mailing Address Current Street Address
KNOXVILLE, TN 37902 KNOXVILLE, TN 37902
City
Phone: office #
State Zip City State
630-818-6996 Mobile # [phone]
Zip
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 Zip
Phone: Office #
E-mail Address
Current Street Address
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:
Fusco Land Planning & Design, PLLC
Name of Registered Agent
P.O. Box 8013
Current Mailing Address
Asheville,NC 28814
city State Zip
Phone: Office # 828-243-6604
[e-mail]
E-mail Address
795 Merrimon Ave. Suite 4
Current Street Address
Asheville, NC 28804
city
Mobile # [phone]
Matthew Fusco
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.
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before me this day and being duly sworn acknowledged that the above form was executed by him/her.
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
THE MICHELE NEUMAIER REVOCABLE TRUST
630-818-6996 630-818-6996
Name
Phone: Office # Mobile #
300 STATE STREET APT. 256
300 STATE STREET APT. 256
Current Mailing Address
Current Street Address
KNOXVILLE, TN 37902
KNOXVILLE, TN 37902
City State
Zip
City State Zip
Deed Book No. 3925
Page No. 418 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item I in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
THE MICHELE NEUMAIER REVOCABLE TRUST john—[e-mail]
Company 2 Name E-mail Address
300 STATE STREET APT. 256 KNOXVILLE, TN 37902 300 STATE STREET APT. 256 KNOXVILLE, TN 37902
Current Mailing Address Current Street Address
300 STATE STREET APT. 256 KNOXVILLE, TN 37902 300 STATE STREET APT. 256 KNOXVILLE, TN 37902
City State
Zip
City State
Zip
Phone: Office # 630-818-6996
Mobile # [phone]
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #