NCC230199_FRO Submitted_20230124

1117122, 10:32 AM
Rowan County
Financial ResponsibilitylOwnership Form Sedimentation Pollution Control Ordinance
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 Rowan County Environmental
Management Department.
Part A Parcel ID Number
1. Project Name
Southern Oaks Subdivision
2. Location of land -disturbing activity (Highway/Street)
Sherrills Ford Rd. Salisbury, Rowan County, NC 28147
Latitude
35.675824
3. Approximate date land -disturbing activity will be commenced
1 /1/2023
4. Purpose of development (residential, commercial, industrial, etc.)
Residential
5. Approximate acreage of land to be disturbed or uncovered
19.54
Longitude
-80.539951
6. Person to contact should sediment control issues arise during land -disturbing activity
Email Address
Per tnicrctJ1,;�" ® 6cIItsCX,7,4. +7-cf
7. Landowner of Record
Kepley Brothers Property Management, LLC
Name
Landowner of Record
Name
459 0150001
Cell Phone Number
701-f
hftps://www.rowancountync.gov/FormCenterlPrint?forml D=96&Preview=YES&Save=False&savedProgress[D= 1 /3

1117122, 10:32 AM
Current Mailing Address
Rowan County
Current Mailing Address
2570 Sherrills Ford Rd.
Salisbury, NC 28147
8. Recorded in Deed Book Number
1410
Part B
1. Person or Firm who are financially responsible for this land -
disturbing activity
Name of Person(s) or Fi (s)
Current Mailing Address
a'�7-70 S►,e.r� r� (S j=0,4 fl� N.C.
Phone Number
J-70-1) aver -1910
Page Number
306
Person or Firm who are financially responsible for this land -
disturbing activity
Name of Person(s) or Fir (s)
Current Mailing Address
25-n vS 4—r; / I S fv -� "
e-el I 1 5 1 uI ,j. c . 2�Y'�
Phone Number
(-70y)o:z- 1�YS
a. If the Financially Responsible Party is not a resident of North Carolina, give name and street address of a North Carolina Agent.
Name of Agent
Current Mailing Address
Phone Number
Name of Agent
Current Mailing Address
Phone 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 the name and street address of the Registered
Agent.
Name of Registered Agent
https://www.rowancountync.gov/FormCenterlPrint?formlD=96&Preview=YES&Save=False&savedProgresslD= 213

1117122, 1032 AM
Current Mailing Address
Rowan County
Current Street Address
Telephone Number
Telephone 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 authority to execute instruments for the Financially Responsible Person). f agree to provide correctional
information should there he any change in the information provided herein.
Name
PvAoe- I kgle
Signature
Title or Authority
C74";M
Date
mm/dd/yyyy I
I 111� C�� otary Public of the County of,(f State of North Carolina, hereby certify that
appeared personally before me this 4ay and being duly sworn acknowledged that the above form was
executed by him/her. itn i my hand and seal of Notary, this day of K# 2tt'
My commission expires
L mm/dd/yyyy 4 � 61 I '�
Seal
Checklist
Download a copy of the Erosion and Sedimentation Control Plan
Checklist (PDF)
https://www.rowancountync.gov/ForrnCenter/Print?formlD=96&Preview=YES&Save=False&savedProgresslD= 3/3