NCC216317_FRO Submitted_20211112

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. Twin Lakes Lot 41
1. Project Name
2.
3,
4.
5.
Location of land -disturbing activity: County Union
City or Township Matthews
Highway/StreetSugar Maple Ln Latitude35.0226 Longitude-80.7010
Approximate date land -disturbing activity will commence: 1 1 /01 /2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.742
6. Amount of fee enclosed: $ 265.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Sandeep Uthra E-mail [e-mail]
Telephone n/a Cell # 704-244-1299 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sandeep & Sunita Uthra
704-244-1299 n/a
Name
Telephone Fax Number
4324 Summer Hill Way
4624 Summer Hill Way
Current Mailing Address
Current Street Address
Winston-Salem NC 27106
Winston-Salem NC 27106
City State Zip
City State Zip
10. Deed Book No. 0275 Page No. 0503 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 at ached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Sandeep Uthra
[e-mail]
Name
E-mail Address
4624 Summer Hill Way
4824 Summer Hill Way
Current Mailing Address
Current Street Address
Winston-Salem NC 27106
Winston-Salem NC 27106
City State Zip
City State Zip
Telephone [phone]
Fax Number n/a

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
Current Mailing Address
City
E-mail Address
Current Street Address
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 State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Eagle Engineering, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Brice Dimitruk 704-315-5734 1-866-775-0329
Individual contact person (type or print) Telephone 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 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.
Sandeep Uthra & Sunita Uthra
Type or print name ��}}
0-`W�"J e
Signature "
Owners
Title or Authority
X10-20/2-924 161 L& 1 ?.01-1
Date
1, CJ10_eJ L I V e 1- -/' ,,--r CU , a Notary Public of the County of _/00�= OF
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State of Nut th Be#b1io&, hereby certify that &xApte—P U� h ro &', 111 a01 rC�_ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal„ this_&f > day ofGYLC9 2
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Mr4, "v ti Seal - f a r -
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