NCC242070_FRO Submitted_20240710

(1) r . FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IREDELL i No person may initiate any land-disturbing activity on one or more acres, '/2 acre or more inside a
C O U N 1' Y N C J watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning& Development, Erosion Control Section.
(Please type or print.)
Part A.
1MS Southeast
1. Project Name
2. Location of land-disturbing activity: County Iredell City or Township Shiloh
Highway/Street Beulah Rd Latitude 35.769852 Longitude -80.003448
3. Approximate date land-disturbing activity will commence: March 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.283
6. Amount of fee enclosed: $ 350 . An application fee of$175.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 9-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed,a flat fee of$135.00 is assessed.
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 Mitch Johnson E-mail Address mjohnsonnjms-se.com
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Francis&Linda Johnson 704-873-1835
Name Telephone Fax Number
105 Temperature Ln
Current Mailing Address Current Street Address
Statesville,NC 28677
City State Zip City State Zip
10. Deed Book No. 783,3017 Page No. 489,285 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
MS Southeast,Inc. mjohnsongms-se.com
Name E-mail Address
105 Temperature Ln
Current Mailing Address Current Street Address
Statesville,NC 28677
City State Zip City State Zip
Telephone [phone] Fax Number
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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:
Frank Johnson [e-mail]
Name of Registered Agent E-mail Address
105 Temperature Ln
Current Mailing Address Current Street Address
Statesville NC 28677
City State Zip City State Zip
Telephone7O4-873-1835 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 by any change in the information provided herein.
Mitch Johnson CEO
Type or print n Title or Authority
y-//- 2`'+
Signatt 'I Date
I, PI V\Id (\� -Kut5 , a Notary Public of the County of -j--t t`L I
State of North Carolina, hereby certify that I I\t1ck ��(,1� appeared personally before me this day
and being duly Togbocknowledged that the above form was executed by him.
Witness ,Ika i d rloti`'ar'8�a1,this ( I.\day of LiI , 20 L
-Iktraf-7RAitita)
Z Not
Fea•
My commission expires Jai/10400M 11' 282)1
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