NCC230951_FRO Submitted_20230418

FINANCIAL EENTATIOON POL UTION CONTROL ACTT
leted and approved by the Land Quality Section,
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 comp ro riate Regional Office.(Please type or
N.C. Department of Environme sedimental Quality. Submit
or the e-mail and/or fax infoed form rmation the ppunavailable,place N/A in the blank.)
print and, if the question is no pp
Part A. Dixie River Road Watermain
1. Project Name Charlotte
Mecklenburg City or Township
2. Location of land-disturbing activity: County Latitude -80.9900
Multiple 35.1770 Longitude
Highway/Street p _
May 1st 2023
3. Approximate date land-disturbing activity will commence: Municipal Sewer
4. Purpose of development(residential,commercial,industrial,institutional, etc.): 12 acres
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
.The application fee of$65.00 per acre(rounded up to
g. Amount of fee enclosed: $780 licaof$fee 0 per
acre
the next acre)is assessed without a ceiling amount(Example: a 9-acre application
7. Has an erosion and sediment control plan been filed? Yes
No Enclosed
X----
g. Person to contact should erosion andsediment control issues arise during land-disturbing activity:
Name
Justin Webster E-mail Address [e-mail]
Telephone
980-312-2768 Cell# Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Varies - See Attached Table Fax Number
Telephone
Name
Current Street Address
Current Mailing Address
State Zip City
State Zip
City
10. Deed Book No. Page No.Varies Varies Provide a copy of the most current deed.
Part B.
rovide a
. Company(ies)or firm(s)who are financially responsible for the
firm isand-disturbing e proprietorship,t►iePname of the owner or manager may hensive list of II
responsible parties on an attached sheet.)if the company
be listed as the financially responsible party. [e-mail]
City of Charlotte
E-mail Address
Name "'f
5 5100 Brookshire Blvd
100 Brookshire Blvd
Current Street:Ad,dtess
Current Mailing Address NC 28216
Charlotte NC 28216 Charlotte
State Zip City
State Zip
City
Telephone
704-497-8801 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:
N/A
--------------------
N/A
Name
N/A E-mail Address
N/A
Current Mailing Address
N/A Current Street Address
N/A
City State
Telephone /A
Zip City State
Zip
Fax Number N/A
(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 N/A
Name of Registered Agent
N/A E-mail Address
N/A
Current Mailing Address
N/A Current Street Address
N/A
City State
Zip City State Zip
Telephone /'4
Fax Number N/A
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.
Joseph C. Wilson
Chief Engineer
Type or print name Title or Authority
Signature
- ---------- ----------------------------- ------ ----------- ---------- ate----- - ------------- ---------- - ------------------
a Notary Public of the County of
State of North Carolina, hereby certify that
personally before me this day and being duly n ac wledgedlthat`the above f
appeared
'Z2
orm was executed by him.
Witness my hand and notarial seal, thi
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