NCC242213_FRO Submitted_20240723

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I LAND DISTURBING ACTIVITY
r7 '` `' Under the conditions set forth by LD Fee Review Fee
l�; Tie New Hanover County
��''. ' yz Soil Erosion and Sedimentation Control Ordinance
Date Pd Date Pd
ngineering Department
pplicant or Applicant's Agent: ACK 301, LLC
[ailing Address: 202 Wagon Wheel Way Telephone Number: 910-443-3014 Fax Number.
Email Address: [e-mail]
Mal Acres of Land Disturbance: 3 2.8 Purpose of Development: S#ormwater Pond
escription of Land Disturbance: Install Storm Water Pond and nessasary swells and drainage piping per plans
ddress of Land Disturbance 301 Crowatan Rd Latitude: Longitude:
STATEMENT OF FINANCIAL RESPONSIBILITY
Land owner(s)of record: Person or firm(s)financially responsible for the
land disturbing activity. If not a North Carolina
resident,you MUST have a N.C.agent.(List Below)
ame: ACK 301,LLC Name: ACK 301, LLC
ddress: 202 Wagon Wheel Way Address: 202 Wagon Wheel Way
ity/State: Wilmington, NC City/State: Wilmington, NC
,p Code: 28411 zip Code: 28411
::lephone Number: 910-443-3014 Telephone Number: 910-443-3014
nail: [e-mail] F umber snail: [e-mail] FaxNumber:
cation of deed(s)or instrument(s): County: New Hanover County Book: RB 6636 Page: 938-939
le above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
'his form must be signed by the financially responsible person if an individual and by an officer,director,partner,attorney-in-
ct. or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
ovide corrected information should there be any change in the information provided herein.
ate: 3/13/24 N . ickb— Tide Managing Member
gnature `_"
Yl M L g ruyr a Notary Public of the County of J&) HaYID y,r _State of
arth Carolina,hereby certify that N t C k\O k C4 S lICk.b appeared personally before me this day and
ing duly sworn acknowledged that the above form was executed by him.
'Rue hand and tart'seal,this r day of I" CVC/h ,202-4-
�ry J1)cL \A W61'; My commission expires a�f � ,1 d
SEAL r I O R k
"%' AUs4, , ,„t,, �3
;rmission to Enter on Lan: f lam'
to'' i n end d in factgrantpermission to the Erosion Control Inspector and his agents to enter on
:ertify that I am authorizedgt�t. pec
e land in question in connection related to this permit application.
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,plication Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION