NCC230276_FRO Submitted_20230223

FINANCIAL, RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 080/2007
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 and/or
fax information unavailable, place N/A in the blank.)
Part A. Twin Lakes Lot 42
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Matthews
Highway/Street 505 Sugar Maple Ln Latitude 35.02224 Longitude-80.70177
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): •71
6. Amount of fee enclosed: $ 350 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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 is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Morrice Blackwell E-mail Address [e-mail]
Telephone [phone] Cell Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Morrice & Samira Blackwell 414-719-5533 nla
Name Telephone Fax Number
10101 Hunt Club Drive 10101 Hunt Club Drive
Current Mailing Address Current Street Address
Mequon, WI 53097 Mequon, WI 53097
City State Zip City State Zip
10. Deed Book No. 5810 Page No 0599 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Morrice & Samira Blackwell [e-mail]
Name E-mail Address
10101 Hunt Club Drive 10101 Hunt Club Drive
Current Mailing Address Current Street Address
Mequon, WI 53097 Mequon, Wl 53097
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.
Nla
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:
Nla
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 Express 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:
Eagle Engineering, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Steven Prophet 7048824222 7043155735
Individual contact person (type or print) Telephone 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 be
any change in the information provided herein.
Morrice Blackwell Owner
ype or print name
�L
Signature
Title or Authority
_--10 110
12�
Date
, a Notary Public of the County of Un\ Q1
State of rth Carolina, hereby certify that �, Q`{ 1 C � �%�y')) iu1 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 Q day of QM , JI'^ 20
LcVA t
KUNJAL PATEL =� Nota ry
SA ARY PUBLIC
Union County My commission expires Ic
North Carolina
My Commission Expires January 28, 2025