NCC201129_ESC Approval Submitted_20200320

FINANCIAL RESPONSIBILITY/OWMERSHIP 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.)
Part A.
Project Name Center Pointe Townhomes
2. Location of land -disturbing activity: County Randoplh City or Township- Archdale
Highway/street Weant Rd Latitude 3,5- ZJ-. Longitude
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):O • �r A
6. Amount of fee enclosed: $ ' The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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;
Name Brian Lucas
E-mail Address [e-mail]
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 attomey-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 be any change in the information provided herein.
Brian Lucas
Type or print am
Si nature
Owner
Title or Authority
12/18/19
Date
I, Sin 6cu A IQ S a Notary Public of the County of "PNan(kn 4c�
State of North Carolina, hereby certify that cvn `- cz C appeared
personally before me this day and being duly swom acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this l � day of _1bQCQ`M0P_a, , 20 �c1
SANDRA DAWES �
Notary Public
Randolph Co., North Carolina
My C m'ssion Expires Nov. 15, 2024 arY
Mycommission expires �crt • t S 2� L�
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