NCC241564_FRO Submitted (2)_20240522

T" ;. Lissara Land,LLC
(.(I ) P. O. Box 281
Lewisville, NC 27023
Lots 126 and 127
361 Lissara Lodge Drive, Lewisville, NC 27023
367 Lissara Lodge Drive, Lewisville, NC 27023
Finanically Responsible/Ownership Form
• Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include
with this form the landowner's 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.
Lissara Land, LLC
Luman L. Wilcox,Jr.
Manager
5,201202q
Date