NCC223483_FRO Submitted_20221012

Print Form
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SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
Au 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
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 has been completed and approved by the Lincoln County Natural Resources Department.
(Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A
1. Project Name Pursuit Church
2. Location of land -disturbing activity: Latitude 35-31-13 Longitude 81-01-35
Parcel Identification Number (PIN) 3695-60-8286 Watershed Area not in a protected watershed
Highway/Street Address 3155 St. James Church Road Denver NC 28037
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.86 +1- Acres
6. Amount of fee enclosed: $ 1800.00 . The Standard Permitting application fee of $200.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 9 acres total $1,800). The Express
Permitting application fee is a dual charge. The normal fee of $200.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight
acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark Allan Kale E-mail Address markk lakenormanmarina.com
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pursuit Church Denver 980-505-5974
Name Telephone Fax Number
PO Box 813 3964 Little Mountain Road
Current Mailing Address Current Street Address
Denver NC 28037 Newton NC 28658
City State Zip City State Zip
10. Deed Book No. 2779 Page No. 253 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
:R`r"sAus. 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY I OWNERSHIP FORM
Part B
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a comprehensive
list of all responsible parties on an attached sheet):
Mark Allan Kale (Pursuit Church) markk lakenormanmarina.com
Name E-mail Address
3964 Little Mountain Road
Current Mailing Address
Newton NC
3964 Little Mountain Road
Current Street Address
28658 Newton NC 28658
City State Zip City State Zip
Telephone [phone] Fax N
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 State Zip
Telephone Fax Number
(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 City State Zip
Telephone Fax Number
(c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can
assist in providing any necessary information regarding the plan and its preparation:
Latham -Walters Engineering, Inc. _ [e-mail]
Engineering Firm or other consultant E-mail Address
16507 A Northcross Drive Huntersville NC 28078
Current Mailing Address City State Zip
James Walters, P.E. 704-895-8484
Individual contact person (type or print) Telephone Fax Number

r_ SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
esau2`s- 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
Name of Person or Firm
Current Mailing Address
Name of Person or Firm
Current Street Address
City State zip City State Zip
Individual contact person (type or print) Individual contact person (type or print)
Telephone Telephone
Fax Number Fax Number
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 by any change in the information provided
herein and any other associated documents. I understand that all documents that are associated with this project and
project number are parts of the complete project document.
Permission to Enter on Land
certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or d to this permit.
Mark Allan Kale
Type or print name Title or Authority
Signature Date
I, �V0 VA; a Notary Public off the County of T_tl'e. oL a II
State of North Carolina, hereby certify that MAo- L� 4A Katst. 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 a *day of :Z if_\1- , 200- Z
Notary
Seal
EVE MONTI
NOTARY PUBLIC
Iredell County, North Carolina
My Commission Expires 2-6-2025
My commission expires a - � r 2 -r—