NCC233310_FRO Submitted_20231106

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
I..iI L RESPONSiE3iLi i T70ifi iERShir rOkrvl
•SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, before this form
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Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
i-cPnionai Office- (Pipase tv1e nr print and, if the ouestirn is not anoiirarie nr the e-ma_ ji address or phone
number is unavailable, place N/A in the blank.)
Part A. .
P jeuLld;:Ef Cie ,si/G-ilA 1 �S fir / 9 / I 9
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
y .j,)�vllitS0.-1 City or Township IAA—lI t/
Esv
� �S6eI.211 activity: County 1:y
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
_ Approximate date land-disturbing activity will commence: C�� -i / ..:'Lt_ �o+►, ©/_L�
of f Pi =IC]n-fFll(residential, commercial, industrial. institutional.
etc..] re reS
6. Total acreage disturbed or uncovered (including off-site borrow and waste areas): /•3a4cres `/ •33
' 6. Amount of fee enclosed: $ 0 O . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
l�f f�vR3 Ji IUUeU i3�.P.uti19.3 br iU ItlI.rIJ .
7. Has ..neT.asior. _HU sediment control lil plan been filed? ...b - Enclosed `: No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 11E --(+(' &' E-mail Address Al. :�S�r"�`.!Jc�� �i, the
COv`
Phone: OfflGe ' �� /^ 3 b .► /
9. Landowner(s)of Record (attach accompanied page to list additional owners):
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Name �1 Phone: Office# Mobile#
errVC rnl R(eruivLr.//
Current Mailing Address Current Street Address
LowLcu.-tie ?0-.3 4ew. 1'//e /Pc a)v,1. 3
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

Par B.
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of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the fandowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Company Name E-mail Address
('� /_t l�z yri . �L � 1�v' ✓Lt/L'�if 4�
C..r- Mailing
Address
4«.,r�€�i __ ��:��€� Current Street Address
City . State Zip City State Zip
Phone: Office# T '�$ Mobile# 3' 4 r6 f
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the landowners signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business!Cg4s 1.F ,aiYname and street address 137 the R'yV€sletz€ T'ac€ei76.
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
-{ City C 4te Z o uty State Zip
Phone: Office# Mobile#
Name of individual to Contact(if Redistered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
rnrs#nA-,:l9:- f`.Irres-4 Q+.- -+ fi rie-7rnz•c City State Zip City State Zip
•
Aobile.._�.�. Once# . ,.�
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name,give name under
which the company is Doing Business As if the Financially Responsible Party is an individual, General
par'tr ,pr h(n or other company not r st reri one fining n rsmeso i'near An ass im e name, attach a copy
of the Certificate of Assgu r Name./
PXr / 51 Rv;/lelVic•
Company DBA Nam
The above information is true and correct to the best of my knowledge and i
belief and was =vvd
by ire under oath, (This pis form must be signed by the Financially Responsible Person if an individual(s)
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 Party). I agree to provide
corrected information should there be any change in the information providedvi herein.
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res r e,..
Typuui p ii ii, i _< €itle or Auu ority.
/15 /G —11- 23
Signature Date
i_ ‘--IN\0,, - 0, *,ir- a Notary Public of the County 1
State of North Carolina, hereby certify that ".§ 5,., , - .. appeared personally
before me this day and being duly sworn acknowledged that the aboe form was executed by him/her.
40 Witness notarial seal, this I 1 day of ._, ', L., C , 20
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7▪ OA' PUBLIC 'C..)Z My commiscior expires 1-, /'
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