NCC232425_FRO Submitted_20230811

talP City of Winston-Salem Field Operations Department I Erosion Control Division
Office: 1.00 E.First Street,Suite 328,Winston-Salem,NC 27101
Wlnslan ulenl Mailing: PO Box 2511,Winston-Salem,NC 27102
Financial Responsibility/Ownership Form
No person may initiate any land-disturbing activity exceeding 20,000 square feet for Single-Family Dwelling construction, 10,000
square feet for any other non-exempt purpose,or part of a larger common plan of development exceeding these thresholds,before this
form and an acceptable Erosion Control Plan have been submitted,reviewed,and approved by the City of Winston-Salem Erosion
Control Division and a Grading/Erosion Control Permit has been issued. Please type or print.Please place"N/A"in the blank space if
not applicable.
Part A
Project Name: Batten Dental Office -Walkertown Landing
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity: 3490 Pearl View Drive, Walkertown, NC Parcel ID# 6868-50-4381.000
Latitude: 36 deg 09 min 48.1 sec N Longitude: 80 deg 08 min 00.0 sec W
Approximate Date that Land-disturbing Activity will Commence: Upon plan approval
Purpose of Grading:
II Commercial 0 Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
Total Site Acreage: 1.499 Acres Acreage to be Disturbed: 1.47 Acres
Grading/Erosion Control Permit Fee: $ 844.00
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: David Bolling Email: dbolling aaJHBATTEN.com
Office Phone: [phone] Mobile Phone: [phone] Fax#: [phone]
Landowner of Record: (use blank page to list additional owners ifneeded)
Parcel PEN#•6868-50-4381.000 Tax Block#: Tax Lot#:
Name: Walkertown Landing, LLC
Street Address/Po Box: 9525 Birkdale Crossing Drive, Ste 200
City/State/Zip Code: Huntersville, NC 28078
Office Phone: [phone] Mobile Phone: Fax#:
Grading Contractor information: (if known at time of-submitting the Erosion Control Plan for review)
Value of Grading Contract: $ City of WS Contractor II7#:
Name of Grading Contractor: NC License#:
Contractor Contact Person: Contact Phone:
Street Address/PO Box:
City/State/Zip Code:

Part B
Person(s)or firms who are financially responsible for this land-disturbing activity: (use blank page to list additional
person(s)or firms if needed) ***Contractors are not considered financially responsible for property not under their ownership***
Name of Person or Firm: Dr. Justin &Ashley Batten, or Assigns
Street Address/PO Box: 2745 Old Hollow Road
City/State/Zip Code: Walkertown, NC 27051
Office Phone: [phone] Mobile Phone: [phone] Fax#-
If the financially responsible party is an out-of-state firm,provide information for the in-state registered agent:
Name of Registered Agent.
Street Address/PO Box•
• City/State/Zip Code:
Office Phone: Mobile Phone: Fax#:
if the financially responsible party is a partnership,provide information for each General Partner:
(use blank page to list additional partners if needed)
Name of Registered Agent:
Street Address/PO Boa:
City/State/Zip Code:
Office Phone: Mobile Phone: Fax#:
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 their attorney-in-fact,or if not an individual,by an officer,
director,partner,or registered agent with 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.
• Type or Print Name: Dr. Justin Batten
Title or Authority: Owner
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Signature: ,� x r —" ,, Date: — 1 f-— ?
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1. 4VVA%. L tiK , a Notary Public of the County of td4a1
State of 1`4 , do hereby certify that V u51h BotOolewli , appeared
personally before me this day,and being duly sworn,acknowledged that the abovep form was executed by him/her. Witness my
hand and notarial seal,this 24' day of Poi' ,20 23
Notary Public Name: J ;, ,, C 114r Jennifer L.West
1 n NOTARY PUBLIC
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Notary Public Signature: 2 LQ��� "`��� North Carolina
. My CQ1111{BbiOrt Erprres November E 202a
My commission expires: h IOU[202H Notary Seal