NCC223285_FRO Submitted_20220920

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 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. Twin Lakes Lot 38
1. Project Name
2, Location of land -disturbing activity: County U n I on __City or Township Matthews
Highway/Street 414 Crepe Myrtle Lane Latitude 35.02135312327511 Longitude-80.70130701567344
3. Approximate date land -disturbing activity will commence:September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residental
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): •70
6. Amount of fee enclosed: $_100.00 . 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 fled? Yes No _ Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Gilbert Butler E-mail [e-mail]
Telephone [phone] Cell # _ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gilbert Butler 317-919-2049
Name Telephone Fax Number
608 Beauhaven Lane 608 Beauhaven Lane
Current Mailing Address Current Street Address
Waxhaw, NC 28173 Waxhaw, NC 28173
City State Zip City State Zip
10. Deed Book No. 8222 Page No.034 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 ormanager maybe listed as the financially responsible party,
Gilbert Butler butlergilshane@ yahoo, com
Name
608 Beauhaven Lane
Current Mailing Address
Waxhaw, NC 28173
City
E-mail Address
608 Beauhaven Lane
Current Street Address
Waxhaw, NC 28173
State Zip City
Telephone [phone]
Fax Number
State
Zip

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:
N/a
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:
N/a
Name of Registered Agent
4t➢�` jt Sa?��'�� ��In � �i��N"31�F °�v`�i�'� ��ys �v�;�s
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City
Telephone Fax Number
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.
Gilbert Butler
Type or p� ame
Signature
Owner
Title or Authority
d-3�z-�
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1, V� arAJ.f W- _ 7a , a Notary Public of the County of w t l S_
State of North Carolina, hereby certify that ¢c-4- 'a + o appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. m Qc fG�n� �wS , /-C.._
Witness my hand and notarial seal; ,this �`��day of !� , 20___
,at`eON
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' [� Ci •' N otary 1
Sea] My Commission Upires
" c' o o Z.
My commission expires November 94, 2024