HomeMy WebLinkAboutNCC221470_FRO Submitted_20220414FINANCIAL RESPONSIBILITY/OWNERSHIP 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. South Skyland Dr
1. Project Name
2. Location of land -disturbing activity: CountyCabarrllS City or TownshipMt Pleasant
Highway/Street S Skyland Dr Latitude35.405118 Longitude-80.445005
3. Approximate date land -disturbing activity will commence: February 15, 2022
4, Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1.32
6. Amount of fee enclosed: $ 200.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Lambert E-mail Address lohn.lambert@prespro.com
Telephone 704-453-2700 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J2 Land Investments, LLC 704-453-2700
Name Telephone Fax Number
6549 Morehead Rd 6549 Morehead Rd
Current Mailing Address Current Street Address
Harrisburg NC 28075 Harrisburg NC 28075
City State Zip City State Zip
10. Deed Book No.14740 Page No. 0070 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.
J2 Land Investments john.lambert@prespro.com
Name
6549 Morehead Rd
Current Mailing Address
Harrisburg NC
City
E-mail Address
6549 Morehead Rd
Current Street Address
28075 Harrisburg NC
State Zip
Telephone 704-453-2700
City State
Fax Number.
28075
Zip
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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 State Zip
Telephone Fax Number
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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 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.
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Si'gKature Date
State of North Carolina, hereby certify that jp� n �r� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Wiitness.gly�� T'AfftWtarial seal,
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