NCC222813_FRO Submitted_20220805

FINANCIAL 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 Environment and Natural Resources. (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.
1. Project Name L_LC
2. Location of land -disturbing activity: County (`D A& )QCity or Township66,c ,
Highway/Street®` of` Li C Latitudes �� 31 3 t�3Z`1 V� Longitude— l
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ ,$� - ,Q4 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Q�tC V ,,,T E-mail Address 1(�t Coy �G r������i�^�1 Ce ►-�
Telephone(f 1%� n \o �0 Cell � NA'ogs Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
T33 (d AUi-,)ke `16? 6E,0eq
Name Telephone
Fax Number
Current Mailing Address Current Street Address.
sum
City State Zip City State Zip
10. Deed Book No. Page No3� —3S 3 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Name E-mail Address
Current Mailing Address Current Street Add ess
City State Zip City State Zip
Telephone0 �0 o79 Fax Number

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