NCC242034_FRO Submitted_20240705

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
/./5;1SEDIMENTATION POLLUTION CONTROL ACT
//5,��7. No 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/
r7/#1,,, or fax information unavailable, place N/A in the blank.) ,
Part A. Lowder CrossingN.'',` :
1. Project Name
rowan 7047010418 ;,,,
2. Location of land-disturbing activity: County City or Township
-`' -80.59638
lowder rd Latitude 35.70238 Longitude `;
07/07/2024 `�`
3. Approximate date land-disturbing activity will commence: ;>, "
- Residential
// 4. Purpose of development(residential, commercial, industrial, institutional, etc.):
%/ 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.9
tik.
''" 6. Amount of fee enclosed: $ 100.00 . The application fee of$100.00 per acre
;i
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
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544 .
7. Has an erosion and sediment control plan been filed? Yes No Enclosed cs
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Carson Ford E-mail Address [e-mail]
L= Telephone [phone] Cell# 618-477-7674 Fax#
, `
9. Landowner(s)of Record (attach accompanied page to list additional owners):
\a CHASE DRM 7047010418
Name Telephone Fax Number
1612 Seattle slew ct 1612 Seattle slew ct
Current Mailing Address Current Street Address
_ waxhaw, nc 28173
`\ waxhaw, nc 28173
• City
State Zip City State Zip
Provide a copy
10. Deed Book No. Page No. of the most current deed.
.\:X 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,
N the name of the owner or manager may be listed as the financially responsible party.
Romelle Chudgar [e-mail]
Name E-mail Address
1612 Seattle slew ct 1612 Seattle slew ct
Current Mailing Address Current Street Address
waxhaw, nc 28173 waxhaw, nc 28173
City
State Zip City State Zip
Telephone Fax Number
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