NCC222197_FRO Submitted_20220701

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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,.
1. Project Name Airport Area
Water Main
2. Location of land -disturbing activity: County Mecklenburg
Highway/Street 3600 Barry Dr. Latitude 35.2356850N
City or Township,
Charlotte
Longitude a948027°W
3. Approximate date land -disturbing activity will commence: �PnvtC 2A2Z
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility (Water Main)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.5
6. Amount of fee enclosed: $ 585 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
E
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ryan LeBlanc E-mail Address [e-mail]
Telephone [phone] cell # 980-259-9439 Fax #
Landowners) of Record (attach accompanied page to list additional owners):
City of Charlotte
Name
300 E. Fourth St.
Current Mailing Address
Charlotte, NC 28202
[phone]
Telephone Fax Number
600 E. Fourth to
Current Street Address
Charlotte, NC 28202
City State Zip City State Zip
10. Deed Book No. 30517 Page No. 918 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firms) 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
Name
5100 Brookshire Blvd.
Current Mailing Address
Charlotte NC 28216
city
Telephone [phone]
[e-mail]
E-mail Address
5100 Brookshire Blvd.
Current Street Address
Charlotte NC 28216
Zip City State Zip
Fax Number �I �-

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 I�Vlailing Address Current Street Address
ft) ILA.
City State Zip City State Zip
Telephone to Fax Number tAlA$
(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 Maili
City
ress
State
E-mail
Current Street Address
Zip City
Telephone nl-�,A� Fax Number �L�'
State
Zip
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.
Type or r nt name Title or
Signa u 9 Date
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him,
a Notary Public of the County of i�eC�le✓t � v��
To S Q Ie C_ W f S o v, appeared
duly sworn acknowledged that the above form was
�5��day of bGLvIe
My commission expires ®f� 3 �/ 2 0 � �