NCC224078_FRO Submitted_20221212

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number is unavailable, place N/A in the blank.)
Part A.
1
Project Name Meadowview Glen
2. Location of land -disturbing activity: CountyAlamance City or Township Graham
Luther Dr. 1 Meadowview Dr. 36.0324579-79,4089415
Highway/Street LatltUde(decimal degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: 10/31 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.96
6. Amount of fee enclosed: $ 1000.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed p No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Michaels E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Land Acquisition and Development Services, LLC 336-282-3535
Name
PO Box 9147
Phone: Office #
Current Mailing Address Current Street Address
Greensboro, NC 27429
City State
10. Deed Book No. 2512
Zip City
Page No. 695
Mobile #
State
Zip
Provide a copy of the most current deed.

Land Acquisition and Development Services, LLC [e-mail]
Company Name E-mail Address
PO Box 9147
Current Mailing Address Current Street Address
Greensboro, NC 27429
City State Zip City State Zip
Phone: office # 336-282-3535 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
David Michaels
Ty p i nt a
Signature
Title or Authority
/71A
Date
I, ��Y)-L E -Ont'4-SiL(I a Notary Public of the County of GUA0-rA
State of North Carolina, hereby certify that NV' L M)6-0Q `5 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this -
KATHERINE R. WHITESELL
NOTARY PUBLIC
GUILFORD COUNTY, NORTH CAROLINA
My Commission ExpiresCD!A-'tQ-')L�
day of ���► 6Lr 20
09-0" i � _ O _` ' r I 1
..
My commission expires fMq �3 j aDXG

Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City
Deed Book No.
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Company 2 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
State
State
State
Zip
Zip
Zip
Zip