NCC240607_FRO Submitted_20240312

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT ii
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INo person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Patterson Residence
1. Project Name
2. Location of land-disturbing activity: County Caldwell City or TownsnipGranite Falls
Highway/Street 6049 Plantation Point Dr Latitude 35.803 Longitude -81.348
3. Approximate date land-disturbing activity will commence: Feb 1, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.75
6. Amount of fee enclosed: $ 100.00 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lacey Patterson E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
John & Lacey Patterson 828-302-7334
Name Telephone Fax Number
3210 5th St Ct NE 3210 5th St Ct NE
Current Mailing Address Current Street Address
Hickory NC 28601 Hickory NC 28601
City State Zip City State Zip
10. Deed Book No. 2083 Page No. 276 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
Lacey Patterson [e-mail]
Name E-mail Address
3210 5th St Ct NE 3210 5th St Ct NE
Current Mailing Address Current Street Address
Hickory NC 28601 Hickory NC 28601
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State ZIp City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
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 of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
John & Lacey Patterson Owner
Type or print name Title or Authority
/ as 0Zq P-;)-ad;9
Sig ture Date
I, Y e roni Ca Shy;<( , a Notary Public of the County of Al2von.c
State of North Carolina, hereby certify that .rpINA PILL, 4 1-0.ce. Pa4eryarN appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 22- day of Spy , 20 VI
VERONICA SHERRILL 'CLA4-1JA''
Notary Public-North Carolina
Alexander County Notary
My CommisSedxpires Aug 28, 2026
My commission expires 9--