NCC232283_FRO Submitted_20230731

P1 .\N MAIM/FINANCIAL RESPONSIBILITY/OWNERSI-IIP FORM
CA l'AWlL:\ COUNTY ('ODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION AND SEDIMENTATION CONTROL
,, l•cr n ma” initiate an land-disturhing activity on one or more acres as covered by the Ordinance before this form
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,411,1 an a.veptable etymon and sedimentation control plan have been completed and approved by the Catawba County
1 III:ties and 1 nginecting Department. (Please type or print, and if question is not applicable,please N/A in the blank)
run ik
1 Job Name 'OUNT DEVELOPMENT
Pl\ or ul I Addrcss 1378104640644
Purpose of de\elopment(residential, commercial, industrial, institutional,etc.)IRESIDENTIAL
4 Approximate soil disturbance date 112/1/22
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) 125.00
h. Has an erosion and sedimentation control been filed? r Yes rj No RI Attached
7. If)ou have an Erosion Control billing account,would you like this to be billed? n Yes No
Account Number INA
PEOPLE
E. Person to contact should erosion and sediment control issues arise during land-disturbing activity
lame (Tina Alexander E-mail address [e-mail]
28-468-7175
Telephone I Cell# I3 Fax# 1
9. Landowner(s)of Record (attach accompanied page to list additional owners)
Name IMICHAEL GLEN YOUNT 1 Telephone I Fax#
Current Mailing Address J5615 HUDSON CHAPEL ROAD
City !CATAWBA State INC I Zip 128609
Current Street Address (SAME
City I j State I I Zip
10. Deed Book No, 3527 ---7 Page No. 0136
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 attached sheet):
li/R Farms LLC
Name E-mail address [e-mail]
0 J7271 Long Island Road
Current Mailing Address
City ratawba State rc Zip 128609

Current Street Address amo as mailing
City I State Zip I --
r04.516.2344•elephoneFax#
2. (a) Ifthe ftnancially responsible party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
Name INA E-mail address
(-went Mailing Address
City I State I Zip I-
Current Street Address I
City I State Zip I
Telephone I 1 Fax#
2. (b) If the financially responsible party is a Partnership or other person engaging in business under 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 I l E-mail address I
Current Mailing Address
---------- --
•ity I State I - Zip I
Current Street Address I
City I State I - - -- Zip -- -
Telephone I Fax# I i
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.
in i'GAta ti
ci C ie/et Dail f
Type or Print ame Title of Authority
- 1,-el ar.1- '19- 10—/3 — �g.a-
Signature Date
I, ' A e ke A-.4..-14_ ,a Notary Public of th9County of oA)..- O 4- State of North
Carolina,hereby certify that M.'e/4L 1 a/' ' y..N appeared personally before me this day and being duly
sworn acknowledge that the above form was executed by him.
Witness my hand and notary seal,this /3 id. day of Def. ,107.2...
III Seal \\`��01ci. 1'1_E Notary
?i.- Notary Public Fes'; My Commission expires 7- 31- ?O 2 7
Catawba
County
My Comm. Exp. i.::: :rintiForr>
07.31.2027 �Q
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