NCC215583_FRO Submitted_20211012

No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and anacceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department cfEnvironment and Natural Resources, (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.
W'���@|��T'D�or�6�U ��fn�� R[�'��O� Improvement �����pf
1� Project / u `^ . .. .°�.^^ , ^^,� Drainage . .~^,`~ ` Project
Mecklenburg[.� �nf�^
^�..E3.."`,~
2. Locatonofkand-d�h�rbing�c�by� Count (�hvorTovvnahi
-[' ��r� || | ~�/�«O��/O1 0«yJ AOo,1Q''�A-�x\8/
.|D.`=��..���� °" °"°. " ." -°° -,��° , ".
Hig t Latitude ' Longitude -
3. Approximate dote land -disturbing activity will commence:
4. Purpose ofdevelopment (reoidentia[commercial, industrial, i
ino(itution�eto]: Storm Drainage |mp"memunt
�
S. Total acreage disturbed or uncovered (including off -site bornom/and vvaato areas): "'""�A
G. Amount offee enclosed: 65000 . The application fee of$GS.00per acre (rounded
uphothe next acre) iaassessed without aceiling amount (Examp|o:aQ-acroapplication fee ia$585).
7. Has anerosion and sediment control plan been filed? Yes NoEnclosed ^~ ��
8. Person to contact should erosion and sediment controissues arise during land -disturbing
NameJosh f"nUrn6aU E-mail Add /CSh@]rmsfnonOO|6n'com
�D�_���-M��� 7O�-���_O/1Q�
T�ephon '"-""^-° °°�� Cell F�m# '"`"�" "`""
A. Landowner(s) ofRecord (attach accompanied page tolist additional ovvnena):
Multiple Owners -See attached Easement Table
Nome Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide acopy ofthe most current deed.
Part B-
1. Person(s)mfirm(s)who are financially responsible for the land -disturbing activity (Provide a
comprehensive list ofall responsible parties onanattached aheeU:
City of Charlotte Storm Water Services
Name
AOO E. Fourth Street- 3rd Floor
Current Mailing Address
Charlotte NC 28202
City State Zip
7O�-���—O-7
, °-, °�"-�°�},
Telephone
E-mail Address
Same
Current Street Address
Same
City State Zip
Fax Number

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
Telephone
Fax Number
State Zip
(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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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 be any change in the information provided herein.
John Keene Project Manager
Tor rint name
2
Si nature
Title or Authority
7/19/2019
Im
a Notary Public of the County of Me-rl- L1410
State of North Carolina, hereby certify that --J c� [-i /) appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witne§ swAV"94 and notarial seal, this c day y of 20
411z On*
M otary
ti Seel
My commission expires_//-) Id