NCC223433_FRO Submitted_20221004

AM
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM 010011111110
SEDIMENTATION POLLUTION CONTROL ACT Ansaww
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 Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Sign the original form in BLUE INK.
Part A. 1. Project Name HALTERMAN RESIDENCE
E
Location of land -disturbing activity: County HENDERSON City FLAT ROCK
Highway/Street US HWY 25 Latitude 35.25175 Longitude-82.43326
Property Identification Number(s) PIN's9576541463
3. Approximate date land -disturbing activity will commence: U PON APPROVAL
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0
6. Amount of fee enclosed: $ 1700.00 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac = $2,900.00).
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 DAVID ODOM, P.E.
E-mail Address [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Keith J. and Debra A. Halterman
[phone]
Name
Telephone
4440 Lake Shore Road N.
4440 Lake Shore Road N.
Current Mailing Address
Current Street Address
Denver NC 28037
Denver NC 28037
City State Zip
City State Zip
10. Deed Book No. 3590 Page No. 533 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.
Keith J. and Debra A. Halterman
[e-mail]
Name
E-mail Address
4440 Lake Shore Road N.
4440 Lake Shore Road N.
Current Mailing Address
Current Street Address
Denver NC 28037
Denver NC 28037
City State Zip
City State Zip
Telephone [phone]
Fax Number N/A

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip
Telephone
City
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.
Keith J. and Debra A. Halterman
Type or print na
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Sin Are
Property Owner(s)
Title or Authority
Da e T
1, Obailurte, Ceo„n a Notary Public of the County of ju(or,ro�
State of 28 hereby certify that AN-, T. � T)clora Q I - LL Orman
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this 1_day of 7uIu 20 �a
Felors
offt Y�-terry Seal
Ceon.Notary Publicnne*lrresSepteftt, 2024
Sea number t377756
My commission expires�,en-4 mI I I , g024