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HomeMy WebLinkAboutNCC223586_FRO Submitted_20221019Print Form ° SOIL EROSION and SEDIMENTATION CONTR L Lincoln County Natural Resources Department ae"Ysouc�es 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-8504 OCT 202z FINANCIAL RESPONSIBILITY/ OWNERSHIP FOW . NA T RE S 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 has been completed and approved by the Lincoln County Natural Resources Department. (Please type or print. If the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.) Part A 1. Project Name Y� -j-z-, 2. Location of land -disturbing activity: Parcel Identification Number (PIN)_ Highway/Street Address_ Watershed 3. Approximate date land -disturbing activity will commence: 1 4. Purpose of development (residential, commercial, industrial, institutional, etc.):(�;Ti 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6. Amount of fee enclosed: $ A420' 6*19 . The Standard Permitting application fee of $200.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 9 acres total $1,800). The Express Permitting application fee is a dual charge. The normal fee of $200.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres to 3,800.00). 7. Has an erosion and sediment control plan been filed? Yes No Enclosed 8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity: Namj7r�",4— (2p�0 E-mail Address 4mw.°C % t�p3Ak�(3.►lr� {Q�,�E3i1f1 Telephone 7�3i Cell # .W�i Fax # I� 9. Landowner(s) of Record (attach accompanied page to list additional owners): r1cow kc' A. C> yz!2 G© i.%AA';567 - SOIL Name T lee phone Fax Number -(-3V D&v\)" v c ga l RmAz,1., Current Mailing Address Current Street Address V ' , OCC ZED �n City State Zip City State Zip 10. Deed Book No, Z-�-)'-}l Page No. vZ­� most recently filed in Lincoln County Register of Deeds. 11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners): ��� Name Telephone Current Mailing Address City Current Street Address State Zip City State Fax Number Zip tCC ii JJ-- 0'55 (Jq a1-bg'ab SOIL EROSION and SEDIMENTATION CONTROL 1 Lincoln County Natural Resources Department rce�sbUK rs./ 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-8504 FINANCIAL RESPONSIBILITY 1 OWNERSHIP FORM 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): AddressName E-mail 02-\ pace, Current Mailing Address Current Street Address C>�- z6o3Q� City "ate � Z,64_ i�p� ,} City State Zip Telephone) d6c1"Gl�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 E-mail Address Current Mailing Address City State Telephone Current Street Address Zip City Fax Number State Zip (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 nameandstreet address of the Registered Agent: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City Stale Zip Telephone Fax Num (c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: Engineering Firm or other consultant E-mail Ao6ress Current Mailing Address City Stake Zip Individual contact person (type or print) Telephone Fax Number SOIL EROSION and SEDIMENTATION CONTROL Lincoln County Natural Resources Department R"s^bU L 115 West Main Street, Lincolnton, INC 28092 704-736-8501 Fax: 704-736-8504 R� FINANCIAL RESPONSIBILITY I OWNERSHIP FORM (d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity: i�-) Name of Person or Firm Name of Person or Firm Current Mailing Address Current Street Address City State Zip City State Zip Individual contact person (type or print) Individual contact person (type or print) T Fax Number Telephone 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 by any change in the information provided herein and any other associated documents. I understand that all documents that are associated with this project and project number are parts of the complete project document. Permission to Enter on Land I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector and his agents to enter on the land in question in connection and/or related to this permit. Type or.-p 'nt n e Title or Authority Signa ure Date --- ------------- ------------------ ------------------------------------------------------------------------------------------------------------ 1, r Sj a Notary Public of the County of j1 d State of North Carolina, hereby certify that � i! i� A, (pre) appeared personally before me this day and being duly sworn acknowledged that the above f executed by him. Witness my hand and notarial seal, this _ ,day ofa \��Sttitll�� RU DIS./ "I' C P 0GO y ommission expires LJ 1;262—