NCC230538_FRO Submitted_20230302

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° ~ SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
115 West Main Street, Lincointon, NC 28092 704-736-8501 Fax: [phone] C C I V E 0
RCSOURGCS�%
FEB 13 2023
FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM
ia,C, HAT RE5
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 r
1. project
2. Location of land -disturbing activity:
Parcel Identification Number (PIN)_
Highway/Street Address ,zc_z�k.
3. Approximate date land -disturbing
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): L "p
6. Amount of fee enclosed: $ +OQi 019 . 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 tot $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name ,�as�te,E-mail Addresscaw�n v.e*-
Telephone_C�]fJ '36'?:> 2Z 1, Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
WRwaZI L52�
Current Mailing Address Current Street Address
:i�wv` , �
City State Zipc� City State Zip
10. Deed Book No. � �/ Page No. / most recently filed in Lincoln County Register of Deeds.
11. Future Lannddo'wnneer(s) if applicable: (attach accompanied page to list additional owners):
4 /'z,
Name Telephone Fax Number
Current Mailing Address
City
State Zip
Current Street Address
City
State
Zip

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R&�s 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY 1 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):
AddressName E-mail
aft _PAnr1a.C1[ e "mac`,
Current Mailing Address
<ga�VVYN . a
City State Zip
Telephone ��7 � U — 4'0
/
Current Street Address
City State Zip
Fax Number A__t
(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
Telephone Fax Number
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 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:
Engineering Firm or other consultant L E-mail Address
Current Mailing Address City State Zip
fndividual contact person (type or print) elephone Fax Number

SIN CGG
{ , - SOIL EROSION and SEDIMENTATION CONTROL
cSbt�RLL Lincoln County Natural Resources Department
�s.' 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY I OWNERSHIP FORA;
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity;
Name of erson or Firm
n Name of Pe on or Firm
'U Q
Current Mailing Address C rur ent Street Address
0G Z.�ot�
City State Zip City — Slate
zip
Indiv€dual contact person (type or print) lndividual contact person (type or print} --- �—
Telephone c� "' �J �� Te€ephone
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 attorrey4n-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 comp€ete project document.
Permission to Enter on Land
I 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 related to this permit.
ti t
Type qr P nt name
- , Title or Author€ty
0Q1
Signafur —�- Date
a Notary Public of the County of{��
State of North Carolina, hereby certify that ond. I
me this day and being duly sworn acknowledged that the above fiorm was executed by himppeared personally before
Witness my hand and notarial seal, this a<� day of 2�JYu j��J 20
� n
NotESENITY HESTCMy commission expires Q" �?�—
TARY PU131_fCcoln County
rth Carolina
n Expires Mar. 292025