NCC232433_FRO Submitted_20230814

11l!J City of Winston-Salem Field Operations Department j Erosion Control Division
Office: 100 E.First Street,Suite 328,Winston-Salem,NC 27 I 0 I
t hlslonSalei 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: Quality Education Seed in Soil Addition
Grading/Erosion Control Permit#:
Location of Land-disturbing Activity:
5151 Lansing Drive
36 .1506987 -80 . 2056921
Latitude: Longitude:
Approximate Date that Land-disturbing Activity will Commence:
Purpose of Grading:
© Commercial ❑ Residential Multi-family ❑ Residential Single-family Subdivision
❑ Residential Single-family Lot/Lots ❑ Other
8 . 13 1.428
Total Site Acreage: Acreage to be Disturbed:
728.46
Grading/Erosion Control Permit Fee: $
Person to contact should Erosion Control related issues arise during land-disturbing activities:
Name: Jimmie Carson Email: jimmie@smithsonnet .com
Office Phone: [phone] Mobile Phone: Fax#: [phone]
Landowner of Record: (use blank page to list additional owners if needed)
Parcel PIN# 6847-45-1746 / 6847-35-8902 Tax Block#: Tax Lot#:
Name: Seed in the Soil, Inc. / Dr. Tamara Turner
Street Address/PO Box: 5012 Lansing Drive
City/State/Zip Code: Winston-Salem, NC 27105
Office Phone: [phone] Mobile Phone: Fax#:
Ext . 3005
Grading Contractor Information: (fknown at time of submitting the Erosion Control Plan for review)
Value of Grading Contract: $ City of WS Contractor ID#:
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 Finn: Seed in the Soil, Inc . / Dr. Tamara Turner
Street Address/PO Box: 5 012 Lansing Drive
City/State/Zip Code: Winston-Salem, NC 27105
Office Phone: [phone] Mobile Phone: Fax#:
Ext. 3005
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: James E, Gadson
1709 CARRAIGE COVE LANE
Street Address/PO Box:
City/State/Zip Code:
Winston-Salem, NC 27127
336-414-6583
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.
Tamara M. Turner
Type or Print Name:
CEO Quality Education Academy
Title or Authority: ...
July 18, 2023
Signature: Date:
Tonya M. Oliphant Forsyth
I, , a Notary Public of the County of
North Carolina Tamara M. Turner
State of ,do hereby certify that , appeared
personally before me this day,and being duly sworn,acknowledged that the above form was executed by him/her.Witness my
hand and notarial seal,this 1 day of '``�j ,20
otto111111111/p of
Tonya M. Oliphant � . Net,
Notary Public Name: � '(ARY
d�of' -A _ MY p�p,ES s
Notary Public Signature: ... _.... -••
r. cOMM��,oN 2 E.)
12/16/24
My commission expires:
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