NCC220060_FRO Submitted_20220106

ISAk
EDIMAL R PtS�l�i�lL97Y/�UliiV���Ba&P �pRM
SEDINTr� T lo7 q POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covers
and an acceptable erosion and sedimentation control plan have been co
and
Quality Section,le e Department i Environmental Quality. Submit the co d by the Act before this form
Regional Office. (Please completed and approved b
unavailable type or print and, if the completed form to the appropthe riate
unavailable, '4
Place N/A !n the blank.) Question is not applicable or the e-mail and/or fax information
Pate A,
Project Name
w��;.F��,�� � � �; irk • I �
2• Location of land-disturbingi !
actfvlfy: County �E�'• 1��uiV !
Highway/Streef y' ? City or Township
- 4 Latitude 5 �j t7 I
3 Approximate date land -disturbing activity will commence: I Longitude
t• Purpose of development (residential, commercial, industrial, i}� i z
Total acreage disturbed or uncovered (including off -site borrow an��I G{`�
6 Amount of fee enclosed: $ d Oaste areas).117 4
UP to the next acre) is assessed without a ceiling amount (Example: a 9-acre a _^
The application fee of $65.00 per acre (rounded
? Has an erosion and sediment control plan been filed? Yes pplfcation fee is $585),
8. Person to contact should Bros No Enclosed
ion and sediment control Name ��1fr% l✓(fi'i5C; � • f issues arise during land -disturbing activity:
E-mail Address
Telephone 70�',701
Cell r j
9- Landowner(s) of Record (attach accomFax 4 {
/ 7 ( c panied page to list additional owners):
Name LLB 3/3- 6790— 2;27 9
Telephone 7
V 4��^ Faz Number
Current Mailing Address
/,, Current Street Address
city �`� c g ---Z76
State
Zip Cit State
10. Deed Book No. Zip
—__ �!_ Provide a copy of the most current deco,
1 • Company lies} or firm(s)w ho are comprehensive list of all responsible nParties on nattached sheet.) ible for the Iftheucoin
proprietorship the name of the owner ormanagermaybe listed as the tinanciath g activity (Provide e
company or firm rs a sole
1� 'i _ n �T L ! responsi6te parry, /J
Name GC
E ma---__ _�Ort /PCeX �2�q � � �2/aC ¢ •,/)� n Address ray
Current _ - � Current Mailing AUd/dre/sse ��
Cityr voA� �% e Current Streef
IAddress
State
zip Clty State —
ZiP

Telephone
Fax Number
(a) If'the Financially Responsible Party is not a resident or North Carolina, give Warne ands =
the designated North Carolina Agent:
street address o,
Name
Current Ulalling Address
City State
Zip
Telephone
E-mail Address
Current Street Address
City
State Zip
Fax Number
as if the nFinanciallyme, o Responsible Party is a Partnership or other person engaging in business 'under an
assumed name, attach a copy of the CeYcificaze of Assumed
is a Corporation, give name and street address of the Registered Agent:
Name. If the Financially Responsible Party
Name of Registered Agenf
Current Mailing Address
City
State
Telephone
E-mail Address
Current Street Address
City
State Zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
or his eattomeyunder an act io ifnot n i de sign by the
Financially
dir,
the authorit to ex Responsible Person if an individual
Y execute instruments for the Financials Responsible Person registered agent with
corrected information should there be any change in the information provided herein.
) 1 agree to provide
i ype or
Title or Authont
>ign e I 2- 21
-- - - - Date
V a Notary Public of the County of
State of North Carolina, hereby certify that
personally before me this day and being dui syti ` �g�ws/t`
by him. g Y orn acknowledged that the above form was appeared
executed
Witness MY hand and notarial seal, this
o' day of 20'
Seal ZmEssion
expires
RYAN CHANDLER
NOTARY PUBLIC
[M:IECCKLENSURG COUNTY MCommission Expires-fQv, ;
._.tl, .__