NCC221475_FRO Submitted_20220414

APR-04-22 02:41 PM WILLIAM E MITCHELL ASSOC 336 540 0060
P. 04
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land4sturbing activity on one or more acres as covered
..form and an acceptable =510n and sedimentation control. plan have OY th@ Act oelbre this
been COMPfated. and pporoVed by
Natural Resources- (PlGaie type 6r print and, if
the question is not aPplicab nvironment and
Land Quality Section, N.C. Department of F
le or the e-mail and/or fax inforrnabon unavailable, Place N/A'fn'the blank.)
J.
Part A.
Project Name
5PF`r04CA5 F%DAf2
Location of land -disturbing activity: County
4 comp.% &Xi-r It 6A City or Townshi a I m_%
Highway/Strunet r T-AMNS
2j) 2
Latitude W
Longltude_JJL;7� #4
Approximate date land -disturbing a(;Vvity will
commence.
-PUrPoset of development (residential, conridnerclal, industriaj,'institutional, etc.:
Total acreage disturbed or uncovered (including Oft -site borrow and waste areas): 47
7 Amount Of fee enclosed: $
Up to the next acre) is ass' The aWcation fee of W%
assessed without a ceiling amount (Example: a 9-acre appli
J Y
Has an erosion and sediment control plan been bled? Yes No
lend ood—K
Person to contact should eros#on and sediment control issues arise during land-distqMin
tty
Name WK
F- E-mail Address
Telephone —ilk—_ _&Z cell# :�3&-432-772
if,7'0 7722 Fax#
­T1rwQ;3V of Record (attach a0companied page to list additional ownersy
Name
Telephone Fax
Current Mailing Address
Current Street Address
City $tx�te ZipCitystate ZP
'10. 'Deed Book No. Page N'
Provide a copy of the most
04' ndeed,
'I.. Person(s) or firms) who are financially 'responsible for the land -disturbing autrvftj '(Pr6vide a: comprehensive list Of 811 responsible P91ies on an attached sheet)-.
PA,4
Name Email Address
_&16 PATF-�1614) �T
Current Mailing Address
Jcve� f4.e,. 2-725E5
City State Zip
Current Street Address
City State
Telephone 5N9
Faxlslurnber 3'-X--625-t4V0
T1

APR-04-22 02:42 PM WILLIAM E MITCHELL ASSOC :536 540 006O
2. (a) It the Financially Responsible Party is not a resident of North Carolina, glys name W ab"t addraw
of the designated North Carolina Agent
Name
Current Mailing Address
CRY fte zip
E-mall Address
Currant F;G—t Address
City
P. 05
Telephone . . . Fax Numb&
(b) If the Financially Responsible Party is a Partnership ,or other person engaging In b.41.99w: undef an
assumed name, attach a Copy of the Certificate of Assumed Name. if the ririindjl�'ResponAi�
Party is a Corporation, give name and street addrm of the Registered Agent E.
L.
Name of Registered Agent R E-mail Address x.
Current Mailing Address Current Street Address
NZI =65
City ewe zi Zip City P
Telephone Fax.Number
-The above Infomudlon Is true and correct to the best of my knowledge and belief ipmvlded.
y me under oath (This form must be signed bye Financially Responsible Pois J"Odmo I
.'h
Cr his ettoey4n-fact or If not an lndMdual, by an officer, director, partner, anti . e e authority to execute instruments for the Financhally Responsible PrMs
e etc pro' i6oriected Information should there be any change In the lhformabon provided herrain."
W or print name TIle or Authority
nature Date
a Notary PLblic of the County of
�*Wto of North Carolina, hereby certify that sK!c-- LR-4-wio appeO W,
onAlly Oefore me this day and being duly sworn acknowledged that tho' si. 00 f6rm irs
cuted by him.
Witness my hand and notarial seal, this =day of Vfj2x=:, 20*1.%
C) J,
0 T Notary
Seat
ti Mycommissionexpires
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