NCC231141_FRO Submitted_20230425

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Check if this project is ARPA-funded ❑
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
Marc and Jill Ryon home
1. Project Name
if this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Burke Icard
2. Location of land-disturbing activity: County City or Township
2193 crestone way 35.774 -81.465
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
May 5th, 2023
3. Approximate date land-disturbing activity will commence:
residential
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
0.94
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
100.00
6. Amount of fee enclosed: $ . 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 ❑x No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Marc Ryon [e-mail]
Name E-mail Address
n/a 828 329 8044
Phone: Office# Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Marc Ryon n/a 828 329 8044
Name Phone: Office# Mobile#
1745 8th Street Drive NE Apt D 2193 Crestone way
Current Mailing Address Current Street Address
Hickory NC 28601 Connelly Springs NC. 28612
City State Zip City State Zip
2634 579
10. Deed Book No. Page No. Provide a copy of the most current deed.