NCC242823_FRO Submitted_20240913

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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/
or fax information unavailable, place N/A in the blank.)
P1.art A.
Project Name i « 1O !k \ ?�_v,z) ()L
2. Location of lanri-dicti irhinn activity: On'intd)Y 0, VA City or Township
Nr7q Nati)na)
ighway/.tree) 1-{Wy _ Latitude`%, "ic30 Lon itude "' 0 9 6
-Th0ry V)✓r (ct NC, a(736.o o�(�
3. Approximate date land-disturbing activity will commence: /4 '/
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
1//2 tore/a-!"
5. Total acreage disturbed or uncovered (in I ing off-site borrow and waste areas): I
6. Amount of fee enclosed: $ /CO/ . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount xample: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes_ No Enclosed
8. Person to contact should erosion and sediment control issues( arise during land-disturbing activity:
Names\ x� ! -mai Rddress
Telephone33kp grAID clq 4 Cell # Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
jC-4\ki\r-6(1)1/4\c\CCS )\\?..A3SIS'' a
Name -Tetepbene Fax Number
�3cF)(�. Cool`d &---
Current Mailing Address Current Street Address
\n, u a`139 0
City State Zip City State Zip
10. Deed Book No. j-i3<2 Page No. 31--iq 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,
i
ame of the owner or manager may be listed as the financially responsible party.
JOso4 6f Vitrs r C
Name E-mail Address
53O ct o,
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone331, g/7 0 997X Fax Number