NCC233127_FRO Submitted_20231019

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Check if this project is ARPA-funded !!l
ACach a copy of the Letter of Intent to Fund
5 )
NERSHIP FORM
LAND ?U,wb(.iTYSFCT;C",J EISEDIMENTAT •N POLLUTION CONTRONANCIAL RE' LCONTROL ACT
No person may initiate any land-distur ing . tivity on one or more acres as covered by the Act, including any
activity under a common plan of deve olpm: t of this size as 4overed by the NCGO1 permit, before this form
and an acceptable erosion and sedim ntat i n control plan have been completed and approved by the Land
Quality Section, N.C. Department of hvini mental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in th bla .)
Part A.
jo
1. Project Name 5 h 0 Ct Ili
*If this project involves A rig Rescue Plan Ac (ARPA)funds. list the Project Name or Project
Number(e.g., SRP-D-A 01 t) below under which you were approved for funding through the
Division of Water Infrastr tur- DWI).
2. Location of land-disturbing activity: County \C�I)w-Q l 9 City nr Townshipp V\Ox I on35.Ls5 3, 5.058#$ -81•Y38117, -8/.938'7a
Highway/Street q 5 shortLatitude d may d r� 9 Longltude(deUmai deQres)'8/13$79
3. Approximate date land-disturbing actitY will commence q h 1)....
4. Purpose of development(residential, ..mmercial, indus ial, institutional, etc.): f:e. ?1 r Pn 1 [a !
5. Total acreage disturbed or uncovere• including off-site orrow and waste areas): 1Jackf
6. Amount of fee enclosed: $ mil, oo . T e application fee of$100.00 per acre (rounded
up to the next acre) is assessed with:ut a ceiling amou t (Example: 8.10-acre application fee is $900).
Checks should be addressed t9 ICI Q. —
7. Has an erosion and sediment cc�rltrof I Ian been filed? Yes U Enclosed No 1
8. Person to contact should erosion an. .ediment control i sues arise during land-disturbing activity.
Name 2ICK' M c ICi nn ' E-mail ddress tom)n f r g wh(J)
Phone: Office# Mobil # 14l1 U —31a t.()
9. Landowner(s)of Record (attac4c^• 1 anie pie to lit additional owners):
tiCV MC(Linn . t inn yav 0
Name Phone. Office# Mobile#
• 4 ,~>i,ot r.. A4 !PA.
urrent Mailing .•.ress Curren Street Address
01dfor+ NC
i , :1009.
City Statei � Zip City State Zip
10 Deed Book N (0,�.p—+ "(I P. t o No. 7"" J E g Provide a c F l! ed.
CAP- Ia i� qqq- Qq5 1 SEP 2 9 2023
CAP- 1 Loa ygq- ygu, l eY._.

Part B.
1. Company(ies)who are financially spo ible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on acco Pan lir page.) If the company is a sole propnetorship or if the landowner(s)is
an ind du l(s), the natrre,(s of t'e�ner(s,/na y be listed as the financially responsible party(ies).
.61 C CV-i n* -
—6 piine+-1-01/4gahoo
Companyriame E-mail Address
allCanifI101.0,61 p -Current Mailingres s Current Street Address
I
OIi vli+- N( a. riXa
City State Zip City /Sttate ¢- Zip
Phone: Office# Mobile# 3Q?g 1122O- p 70?/
Note: If the Financially Responsible 1 arty , not the owner ofl the land to be disturbed, include with this form
the landowner's signed and dated written c sent for the appli4ant to submit a draft erosion and sedimentation
control plan and to conduct the antici led and disturbing activity.
2. (a) If the Financially Responsible 'Ii
rty a domestic company registered on the NC Secretary of State
business registry, give name and ee address of the Registered Agent:
Name of Registered Agent E-mail ddress
Current Mailing Address Current Street Address
—
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registe ed Agent is a company)
(b) If the Financially Responsible:Party s not a resident df North Carolina, give name and street address
of the designated North Carolina agen who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail ddress
Current Mailing Address Curren Street Address
City State I Zip City State Zip
Phone: Office# Mobile
Name of Individual to Contact(if 4egis red Agent is a coMpany)

(c) If the Financially Responsible arty s engaging in busi ess under an assumed name, give name under
which the company is Doing Busness As. If the Financ:Ily Responsible Party is an individual, General
Partnership, or other company not registered and doing b siness under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form mustlbe s fined by the Fina cially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an indiv dual, by an offic:r, director, partner, or registered agent with
the authority to execute instrum nts `or the Financial y Responsible Party). I agree to provide
corrected information should then be ny change in the information provided herein.bf
Typ r print name Title-Or Authority
' \ (\, . ..,C.._ /Lisisii, 1,\,e /Date t 1
I, D.QSSs co- Q,- -Vrctic-,_srN , a Notary Public of the County of t�C_0D 4-442.-\1
State of North Carolina, hereby certify that 9);L.K1 mcY,,,rey�; 4-kM7_t CAA Lat4eappeared personally
before me this day and being duly -wor i acknowledged that the above form was executed by him/her.
Witness my hand and notarial se-1, this i 3 day of 5e -Q r-�b--t.-✓ , 20 ?5
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c? p1ARy. "1/:';, Note
lip
U- My c•mmission expires . iJ2- T
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