NCC230574_FRO Submitted_20230314

° °G� SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department r�r.
RuiCc�s 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
tr r. JOIN 3 1 202Z
FINANCIAL RESPONSIBILITY/ OWNERSHIP FORM Lincoln County
Natural Resource �
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
2. Location of land -disturbing activity:
Parcel Identification Number (PIN)
Highway/Street Address AigD lr
`' - 1. lozg9 4
Longitude 10241CkI
Watershed Area I �rhr;S C're e4
ST11-11q-1 - (0 101999
lr�►1r�1 r"Dn, �� 28 a9 2
3. Approximate date land -disturbing activity will commence: Ma_ Gh Zb 2
4. Purpose of development (residential, commercial, industrial, institutional, etc.): 2esi DIE NTin-L
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 . 0 its
t�
6. Amount of fee enclosed: $ u
I V . 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 Enclosedy
S. Local appointedperson
.�tt-o-- contact should erosion and sediment control issues arise during land -disturbing activity:
Name _ , }} l i +��
y L Lm in r( E-mail AddressLA!Jd2 e O S6. 4
Telephone Cell#_a Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
El IIvA E.�109c 1 e N . Lay -A %4 - L# r7 S- Z 240
Name Telephone Fax Number
1$3 rl _ nO W r+e )11 I/ane
Current Mailing Addr ss Current Street Address
h No, 28092
City 4 State Zip City State Zip
10. Deed Book No Zgq ` Page No. 2 I most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Telephone Fax Number
Current Street ess
CIV7 State Zip

c° SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R�N.SOURcr5 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
lis of all responsible parties on an attached sheet):
1 -Lad Loy Vid 2 o 11!5,a,, 41 .PICA--
Name E-mail Address
Current Mailing Address Current Street Address
r
City State Zip City State Zip
Telephone AVvzi- ZZ Y o Fax Number
(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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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 preparatiqD:
Engineering Firm or other consultant
Current Mailing Address
City
State Zip
Individual c person (type or print) Telephone Fax Number

$Go�N O SOIL EROSION and SEDIMENTATION CONTROL
a Lincoln County Natural Resources Department
xr"�s�'u `cs 116 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone] — _P_
FINANCIAL RESPONSIBILITY/ OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
7:�,11 � ►. !n, , a I
Name of erson or Firm Name of Person or Firm
1937 M�rl �, It, .
Current Mailin Address Current Street Address
L ✓t �J c F ?v4 z
City State Zip
City
State Zip
Individual contact person (type or print) Individual contact person (type or print)
Telephone - Zz4o Telephone
Fax Number
Fax Numbe
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
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.
� /,--
Type or l6rint name Tiffe or Authority
Signature bate
I, b4nitilt f6d 1 rj1 1 -,a Notary Public of the County of Unco in._
State of North Carolina, hereby certify that I. appeared personally before
me this day and being duly sworn acknowledged that t e above form was executed by him.
Witness my hand and notarial seal, this 3 ! day of
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