NCC232257_FRO Submitted_20230727

ru lilt rut III
rifki SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
RN , 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 Name 4-11Q&*\(\taji tc'0
2. Location of land-disturbing activity: Latitude tZiet/ Z Longitude ---et• 13-603
Parcel Identification Number(PIN) WatershedArrea, ��(u� ,
Highway/Street Address V.410. bL w 1,W Ln r r � -
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential,commercial, industrial, institutional, etc.): CDVVWhe-A 'e
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): t ,
6. Amount of fee enclosed: $ WO. 00 .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 tot $3,800.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Local appointed personto contact should� erosion and sediment control issues arise during land-disturbing activity:
Name % ri0 p"1' t209•C` ` E-mail Address
TelephoneL)OJe&€ — 1i41 Cell# Fax Fax# kV
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Name Teleph ne Fax Number
17-0 Ox. 4k 4400 w LebiN
Current Mailing Address Current Street Address
beA u '1 'I•DC' ? j03") ( ..©l,v v\
City �7 State Zip City State Zip
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10. Deed Book No. )lj Page No. I most recently filed in Lincoln County Register of Deeds.
11. Future Landowner(s)if applicable: (attach accompanied page to list additional owners):
trAA-
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip

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•,. SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
R A ti ts- 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):
5,04CM LeC3a.01 P -k-`53s, WC roach 1 ®c k\aks-kes-,nek-
Name E-mail Address
`Po D, DEC 4-304n to Lance
Current Mailing Address Current Street Address
Zelf7en Ui,U`cokh+k-DY`l 13 C 2 2'O? 2�
City State//-- Zip City State Zip
Telephone CVO &O 1— M, Fax Number WA.
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:
PAL
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:
'A1 fir. m c�n`14- v c-k-e�,r,r�
Name of Registered Agent C? E-mail Address
Current Mailing Address ^� Current Street Address
1,�y�/'��
City State/ �p Zip City State Zip
�r) 40 Telephone C')o 6'� 41 Fax Number
(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:
Engineering Firm or other consultant E-mail Address
2) 0 VIa ,CQ A 4k-0 t L %InCOl,tNDV\
Current Mailing Address City State Zip
'Dow tip,L.ea.$c ( 3a 1€aa t--L�,�...
Individual contact person(type or print) Telephone Fax Number

ioorc- --6-e,, SOIL EROSION and SEDIMENTATION CONTROL
Lincoln County Natural Resources Department
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:
Wo2C...,
Name of Person or Firm Name of Person or Firm
Current Mailing Address Current Street Address
City State Zip City State Zip
Individual contact person (type or print)Individual contact person(type or print)
Telephone Telephone
Fax Number 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 authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector
and his agents to enter on the land in question in connection and/or related to this permit.
POAI)4/11 ir-LOCkC is TR. 4,ic e\,-k---
Type print name Title or Auth ity
� �� ( re--- 14-2 3
nature Date
BC1 1`g0.Nw L ,/_.ir A'N ,a Notary Public of the County of L / Ki C-0 / ice..
State of North Carolina, hereby certify that °Med c/.Sco&f R O A'CAN ' A-appeared personally before
me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this 3 day of Zcu iv I._ ,20 a-3
ow..--
Notary
4 --a7- a (�' y My commission expires T
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