NCC231107_FRO Submitted_20230419

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dControl Division
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MY r�It� �t an1ntr-d rstu rbititart l
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.��� q�N�r� ���t or � ir�gle-l�`amil Dwelling construction,
for any other ra it-erye lli p( IIII I -pose. or part
f rmE larger o���mmi plan of d v lop rat exceeding these thresholds* before this
�� �r1 ��ta�le Erosion r�trl l�lati 1��
Control D submitted, reviewed, rr hfitf i r m�
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Location OfLand-disslurbingy 36
Activity: v it Mai**...t#i ■, *its Pe!jR.Avenuei■t*i*aYoo*i+if&****A iWoi.*'Y# no POB**i r i i a E E sea r#****iiir'■ b6rt*ir•**0■*W***t*rt}*.*I**ttr■■■ttt44*000*f0644
Latitude: L*Ni 36.136910
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Longitude' ■ Mir■M'.32*,0i**.
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Approximate t that Lard -d' turb i �•N June
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l'urPOse of rain
[K Commercial D Residential Multi -family
El Residential ingic-failii Lot/Lots
ge 4 5.3 5
Total Site Acrea . Noel 411 4,11P Wd film ■■B0sE****4aarittii•riii#taa■tatri�r�fi
Grading/Erosion ntrol Pe riii i t Fee: Br .
84400
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L1 Residential Single-family Subdivision
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Acreage to be Disturbed. rtt.triii'i.0
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Person to contact shotild Erosl*on Control� related arise during l��r� � d Stu rbinactivities:
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Poore
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Prc l PIN -6837-50-6835�Y y�J`
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Cat/State/Zip Code:...■Wi n sto n Sa IemNC2
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StreetAddress/ Box:
2700 Boulder Park Ct.
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Name oRegistered Agent t
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The above inforivad n is true and correct to the best of my knowledge and belie` and was provided by me under oath. This form
m u t be signed by the lei n Brie i al ly res pon s i bl a pe r on, i f an i j1d i grid u 1, • or the i r attnnie - i - `act, or if not an individual, by an officer,
i rector, partner, or registered agent Nvith author.it to execute instruments for the firm c i a I ly re pons1 ble person. as ree to prov id
corrected informal ion should there he any change ire the information provided herein.
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Thomas Clark
Typeor Print Na i■r!T■#i+•4■+1+=+FN Ft■ri■■4f#t■i*■■ttif■+t■iT!■■itta fT*f■■t■tiN■#t■■*■ii■tM ftf##t#Fit■*N■■ra■■t■aiT#atf#t#tT tf•i!f#f■t/F*taf■t■iit t#+t■■i i■i■#Ff ara■a■if■ri
Title
eralM ana
Authority: Gen& f i+. i F t t i r t■ t r•+ F+■ i■ 1•..gef,t t■+■ r■*■ t i poi 0 r■ 00 Y■ *a r■ i F Y i t i■■■ a i■ t■■■ Y t f rt* to 0 t i t# oil- f i f WO 9 t# PO Of WO * t* t* rt■ f F+ t f rt t t i F f t f rt M t■ F t t i t •* i i i i 64 ■•i 04 404 a ■ * i ii i ■
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personally before ine this day, and being duly sworn. acknowledged thm the above f nia was executed by him/her. Witness ni \-
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li-and and notarial seal, this ■rti�rti##.ii■rr■rlrirtrT■#i�f4t■*i�■Y■*r�ii■riiii■■riii#aa■■■*##��fffff#�**ff day of..,.a.. t ■ ■*tT#ytr++�� � ��*fi+*■.t.�.*f*rti***.t��t#.**TT*�*f*■# � ■■ � ••
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Notary PubliSi ntur■ .,.. **rtrt�FirtariiirtafrTt#N!F C■■My iif*■iFiiii},ii
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i;� 4 ion expires: +N Yiiiiii +. ■ ■iii iiiYii■■ri#■� . 4 ■ F iia ■*rt*fir*#
WILLIAM C%ORBIN
Notary Public
ForsYth Co., None Carolina
My (;C)mMjssion Expites Feb.. ��, 2028
Notary Seal