NCC230700_FRO Submitted_20230317

Print Form
G � L2 SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
NATURAL 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
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 N/A in the blank.)
Part A
1. Project NameCLARK CREEK LANDING
2. Location of land -disturbing activity: Latitude35°30'42.81"N Longitude8l *1 5'28.55"W
Parcel Identification Number (PIN)3624783620 Watershed AreaCATAWBA RIVER BASIN
Highway/Street AddressSTARTOWN ROAD AND CLARK CREEK ROAD
3. Approximate date land -disturbing activity will commence: SEPTEMBER 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):64.324 ac.
6. Amount of fee enclosed: $13,000 . 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 total $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameTOMMY LEPPERT
Teler)hone704-751-7110
E-mail [e-mail]
Cell # N/A
Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
BBC CLARK CREEK, LLC 704-751-7110 N/A
Name Telephone Fax Number
21000 TORRENCE CHAPEL RD, STE 100
Current Mailing Address
CORNELIUS NC 28031
City
State
21000 TORRENCE CHAPEL RD, STE 100
Current Street Address
CORNELIUS NC
Zip City
State
28031
Zip
10. Deed Book No.3164 Page No.142-145 most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s) if applicable: (attach accompanied page to list additional owners):
Name
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip

N-C� SOIL EROSION and SEDIMENTATION CONTROL
a ` Lincoln County Natural Resources Department
RrNbwR2 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / 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):
BBC CLARK CREEK LLC [e-mail]
Name
21000 TORRENCE CHAPEL RD, STE6
Current Mailing Address
CORNELIUS NC 28031
City State Zip
Telephone[phone]
E-mail Address
21000 TORRENCE CHAPEL RD, STE 100
Current Street Address
CORNELIUS NC 28031
City State Zip
Fax Number N/A
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 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:
BRIAN MAHONEY [e-mail]
Name of Registered Agent E-mail Address
21000 TORRENCE CHAPEL ROAD ST6 21000 TORRENCE CHAPEL ROAD STE 100
Current Mailing Address Current Street Address
CORNELIUS NC 28031 CORNELIUS NC 28031
City State
Telephone[phone]
Zip City
Fax Number N/A
State Zip
(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:
YARBROUGH-WILLIAMS & HOULE, IN& [e-mail]
Engineering Firm or other consultant E-mail Address
PO BOX 1198 PINEVILLE NC 28134
Current Mailing Address City State Zip
VINCENT G. KEENE, PE 704-556-1990 704-556-0505
Individual contact person (type or print) Telephone
Fax Number

SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
RC50GR.tS 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: [phone]
FINANCIAL RESPONSIBILITY / OWNERSHIP FORM
(d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity:
PRESTIGE SITEWORKS LLC
Name of Person or Firm
Name of Person or Firm
21000 TORRENCE CHAPEL RD, STE '© 21000 TORRENCE CHAPEL RD, STE 100
Current Mailing Address Current Street Address
CORNELIUS NC
City State
TOMMY LEPPERT
28031 CORNELIUS INC 28031
Zip City State Zip
Individual contact person (type or print) Individual contact person (type or print)
704-751-7110
Telephone Telephone
Fax Number N/A 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 aLith<ized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents Venter op the land in question in connection and/or related to this permit.
BRIAN MA NEY "2A.A 6ev' �AaAaQ26�
Type or pri t a Title or Authority
S-Z&- M22_
Signat Date
i.�t— lT � , a Notary Public of the County of �.i0�/I�
State ofNe Carolina, hereby certify that appeared personally before
me this day and being duly sworn acknowledged that the above form was exec ted by him.
Witness my hand and notarial seal, this2-4*)t: day of Al A , 20 2--2-•.-
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