NCC231434_FRO Submitted_20230511

ECCm 22- 0/D24
'l 2-COM-OS
SOIL EROSION and SEDIMENTATION CONTROL-_,
Lincoln County Natural Resources Division s:- 4JED
a«,R 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FEB 2C7021
FINANCIAL RESPONSIBILITY / OWNERSHIP FORMcoln County
Natural Resources
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 Division. (Please
type or print. If the question is not applicable or the e-mail and/or fax information unavailable,place N/A in the blank.)
Part A
1. Project Name EROSION CONTROL PLAN FOR LOT 7 BALSOM RIDGE ROAD
2. Location of land-disturbing activity: Latitude 35.5436 Longitude_81.0400
Parcel Identification Number(PIN) 86906 Watershed Area WS-IV-PA
Highway/Street Address Parcel 86906 Lot 7 Balsom Ridge Road, Denver,NC
3. Approximate date land-disturbing activity will commence: February 1,2021
4. Purpose of development(residential,commercial,industrial,institutional,etc.):_lndustrial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):_DISTURBED AREA:2.0 AC
6. Amount of fee enclosed:$ 400.00 .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 x_No Enclosed_x_
8. Local appointed person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Eric Reilly E-mail [e-mail]_
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
_US Development Group of NC, LLC(dba Bakeology)__ [phone]
Name Telephone Fax Number
_141 Magnolia Farms Lane Same
Current Mailing Address Current Street Address
Mooresville, NC 28117
City State Zip City State Zip
10. Deed Book No. 3119 Page No. 52 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Same as Above
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

}}¢¢�„vN SOIL EROSION and SEDIMENTATION CONTROL
1J 6 3t �i
Lincoln County Natural Resources Division
RAR , 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / 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):
_US Development Group of NC, LLC(dba Bakeology)_anwarhussein65Pgmail.com
Name E-mail Address
141 Magnolia Farms Lane_ Same
Current Mailing Address Current Street Address
_Mooresville, NC 28117
City State Zip City State Zip
Telephone [phone] Fax Number
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:
n/a
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:
n/a
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:
_Jeff Swartz, PE [e-mail]
Engineering Firm or other consultant E-mail Address
585 B and T Lane,Taylorsville,NC 28681
Current Mailing Address City State Zip
Jeff Swartz, PE 828-632-0499 _
Individual contact person(type or print) Telephone Fax Number

SOIL EROSION and SEDIMENTATION CONTROL
.y.. . Lincoln County Natural Resources Division
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sacif 5,f 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d)Contractors and/or Subcontractors(person(s)or firm(s)engaging in the land-disturbing activity:
Crescent Structures(Eric Reilly)
Name of Person or Firm Name of Person or Firm
_914 Moose Street
Current Mailing Address Current Street Address
Gastonia NC_ 28056
City State Zip City State Zip
Eric Reilly
Individual contact person (type or print) Individual contact person(type or print)
Telephone_704-913-5947 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)r I agree to provide corrected information should there by any change in the information provided
herein and any other'associated documents.!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.
Anwar Hussein _US Development Group of NC,LLC(dba Bakeology)_
Type or print lame Title or Authority
2/ / z -Z
Signatur Date
•
l TGri: hn �i-0 d ,a Notary Public of the County of 56e../hy
emState of s,hereby certify that Anocti^ ((SSA 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! (day of FC L4,44 ,20 i' 7'
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