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HomeMy WebLinkAboutNCC222181_FRO Submitted_20220613FINANCIAL 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. Palisades at HickoryCreek 1. Project Name 2. Location of land -disturbing activity: County Cleveland City or Township Shelby Highway/Street S Dekalb Street Latitude 35.26668 Longitude 81.54291 3. Approximate date land -disturbing activity will commence: November 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.66 6. Amount of fee enclosed: $ 1560 . 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 William E. Ratchford E-mail Address william.ratchford@southwoodrealty.com Telephone (704) 869-6204 cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Southwood Realty Company (704) 869-6024 Name Telephone Fax Number 165 S York Street 165 S York Street Current Mailing Address Current Street Address Gastonia NC 28052 Gastonia NC 28052 City State Zip City State Zip 10. Deed Book No. 1823 Page No. 1347 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. Southwood Realty Company william.ratchford@southwoodrealty.com Name E-mail Address 165 S York Street 165 S York Street Current Mailing Address Current Street Address Gastonia NC 28052 Gastonia NC 28052 City State Zip City State Zip (704) 869-6024 Telephone 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: Name Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip 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 Current Mailing Address City State Telephone E-mail Address Current Street Address Zip City State Zip 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. Herman E Ratchford Jr Type or print name .x� Signature State of North Carolina, hereby certify that - personally before me this day and being executed by him. President - Southwood Realty Company Title or Authority C`v4' \ Date a Notary Public of the County of C—>a,S�:j c� o, �F is ��Z-Q _TC appeared luly sworn acknowledged that the above form was _�\ Witness my\+hand and notarial seal, this l6 day of,-�� �� , 20 a \ kN Ju�7a4A N tary I ` My commission expires W A