NCC231922_FRO Submitted_20230622

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—�c+uNrr FINANCIAL RESPONSIBILITY/OWNERSHIP FORM H RsoN�i" � r
!+enroE� ' SEDIMENTATION POLLUTION CONTROL ACT eN��
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 Henderson County Site Development Department. (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.)
Sign the original form in BLUE INK.
Part A.
1. Project Name Bane Road Subdivision Local Road
2. Location of land-disturbing activity: county Henderson City (County)
Highway/StreetBane Road Latitude35.321128 Longitude-82.634372
Property Identification Number(s) PIN's 9519-60-7981, 9519-61-7200, 9519-61-4194
3. Approximate date land-disturbing activity will commence:June 19, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):5.5
6. Amount of fee enclosed: $1850 . The application fee of $300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a $200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac= $2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tom Pollock E-mail [e-mail]
Telephone [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pollock Land LLC 913-271-6746
Name Telephone
30 Cherokee Trl Same as Mailing
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip
10. Deed Book No.3737 Page No. 1 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Tom Pollock [e-mail]
Name E-mail Address
30 Cherokee Trail Same as mailing
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip
Telephone 9l� -6746
Fax Number
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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
(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
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.
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Signature Date
I, Ottrjil&fel Cyr , a Notary Public of the County of LcUr
State of 1\1 L , hereby certify that /14 f) G(cL�l---
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
1_ dayof �� 20
Witness my hand and notarial seal, this �✓11,(�
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1 Notary P Notary
Henderson
Seal = y CCounty = ��
Momm. Exp. My commission expires 10/ cog/i
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Landowner(s) of Record (accompanying page, to list additional
owners):
Name: MORGAN, RALPH
LEE;MORGAN, ROBIN M
Telephone: [phone]
Current Mailing Address: 323 Bane Rd., Mills River, NC
28759
Current Street Address: Same as mailing
Deed Book No. 1420, Page No. 638
Name: PISGAH TRAILS BASECAMP
LLC
Telephone: [phone]
Current Mailing Address: 30 Cherokee Trail, Fletcher, NC
28732
Current Street Address: Same as mailing
Deed Book No. 4003, Page No. 171
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