NCC220612_FRO Submitted_20220203

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. Mount Holly Pumping Station & Stowe HW/IPS
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street Hawfield Rd Latitude35.279151 Longitude-81.001633
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 24
6. Amount of fee enclosed: $ 1,170.00 . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nicole Bartlett E-mail Address [e-mail]
Telephone [phone] Cell # 704-497-8801 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Charlotte
Name Telephone Fax Number
600 East Fourth Street 600 East Fourth Street
Current Mailing Address Current Street Address
Charlotte NC 28206 Charlotte NC 28206
City State Zip City State Zip
10. Deed Book No. 28400 Page No. 380 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,
the name of the owner or manager may be listed as the financially responsible party.
City of Charlotte [e-mail]
Name
5100 Brookshire Blvd.
Current Mailing Address
Charlotte NC 28216
City State Zip
Telephone [phone]
E-mail Address
5100 Brookshire Blvd.
Current Street Address
Charlotte NC 28216
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address
N/A
City
Telephone N/A
State Zip
Current Street Address
N/A
City State Zip
Fax Number N/A
(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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
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.
Joseph C. Wilson
Typr rint name
Sign e
Chief Engineer
Title or Authority
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Date
I, YY?4E,5 (j,`,y►cG , a Notary Public of the County of
State of North Carolina, hereby certify that _C�iP C c .r t W,i _ 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
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Mount Holly Force Mains
Mecklenburg Charlotte
Hawfield Rd 35.279151-81.001633
January 2020
Municipal
5 acres
325.00
Kq
Nicole Bartlett [e-mail]
[phone] 704-497-8801
9. Landowner(s) of Record (attach accompanied page to list additional owners). -
City of Mt Holly
Name
PO Box 406
Current Mailing Address
Mt Holly NC
City State
10. Deed Book No. 0862
Charlotte Water
Telephone Fax Number
400 E. Central Ave.
Current Street Address
28120 Mt Holly NC 28120
Zip City
Page No. 206
State Zip
Provide a copy of the most current deed.
5100 Brookshire Blvd. 5100 Brookshire Blvd.
Charlotte NC 28216 Charlotte
ITA IV, • ::1
NC 28216