NCC232623_FRO Submitted_20230830

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CPT Engineering and Surveying, Inc.
4400 Tyning Street•High Point,North Carolina 27265 o Phone[phone] o Fax[phone]
LETTER OF TRANSMITTAL
To:NCDEQ Winston-Salem Regional Office Date: 08-08-23 Job No: 1316-14
Land Quality Section Attention:Nicole Chiles Assistant Reg.Eng.III
450 W.Hanes Mill Rd.,Suite 300 Re: Mebane Towne Center,Ph.T1B,
Winston-Salem,NC 27105-7407(336)776-9800 Road Widening,S.Fifth Street.Mebane,NC
We are sending you:
® Attached ['Under separate cover via: Fedex the following items:
❑Plans ❑Diskette(s) ❑For Approval ❑For Review ❑ Specifications
❑ Other:
Quantity Dwg.No. Description Status
1 - Orig.Financial Responsibilty Ownership Form H
1 - Check payable to"NCDEQ" for$200.00 H
1 - Copy of Approved NCDOT Encroachment Agreement H
1 - Copy of Keystone Group,Inc.Deed H
3 - Sets of Erosion Control Plans H
Status Code: A. Approved D. Rejected-See Remarks G Approved-As noted
B. Sign and Return E. For your information H. As Requested
C. Amend and Resubmit F. Refer to Remarks I. Review and Comment
Remarks: Please find attached the above-described items for NCDEQ(Erosion Control)Review/Approval.Feel
free to call with any questions or comments.
Mike Venable
CPT Engineering and Surveying,Inc.
Ext.305
E-mail: [e-mail]

Check rf this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
i OE`J'ANIC0AL G ESPO 5SOL t OTi Y/OVMEi`ISMP FORGIJ
LG�OE�fuL(�11G ''O Oti POLLIMON CON'iritiO .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 NCG01 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.)
Par A.
1. Project Name pia 1414E T©v4r.4 f ` l J �o➢4•T1 `r. t ld 9 �, ., tntti?k:t4iitj �� •P . l k� a ete)
"If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County ALAivi iNCE: City or Township CFtf AiiiE
Highway/Street Latitude(declmal degrees)36,0 7S` Longitude(declmal degrees) ""7 r l
3. Approximate date land-disturbing activity will commence: hS SUod po.si)
4. Purpose of development(residential, commercial, industrial, institutional, etc.): (UM) d➢l E iot',i
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): P•cd 6a1{eta. n'
6. Amount of fee enclosed: $ 2,co a0 . 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 0 Enclosed 0 No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name SAKI ki 2t Et2: tBS E-mail Address eziij it 6 2cpt,C-a L.(.6
Phone: Office# 14J4 Mobile# (736) r✓C) 2rucb
9_ Landowner(s) of Record (attach accompanied page to list additional owners):
NCPOT
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
371) 3 AL1,,fAikki Og.j1E
Current Mailing Address Current Street Address
t;ge r.l 1Qgo plc-. z74/0.7
City State Zip City State Zip
Deed Book No. 3$3, Page No. In Provide a copy of the most current deed.
Ps4T i CvlL 62- PAGE 3V0
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

lamx
Pen .
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landov✓ner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
1?.. op wilt ,fr t` �'c'��t' !c:4t e
Company Name E-mail Address
:MO 1:;.t-t,.Ca,1A T 06!ll( 3 ii R-LLI A-,tilLi`-, 1)/2i 4
4-
Current Mailing Address Current Street Address
5 6 t�°G Z 19i 1 G(Z GrJ.501.:lzz.) Nit • F07
City State Zip City State Zip
Phone: Office# (530 Seal: --frtii' Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Cevdficate of Assumed umed Marne.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
r ,,✓ b46, bv 4/. • 1 T
Type or print name Title or Authority
;�� e� / 3
Signature Date
I, L '%E�jr,�f L,/: /!a re. a Notary Public of the County of Z.v;t` ,74)
State of North Carolina, hereby certify that �J S c o � 1.JA-` 1,4 LE appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this -) day of f/ 5 I , 20 -3
L TEMPLE WALLACE + Notary')�
Seal NOTARY PUBLIC i
GUILFORD COUNTY, NC 1 -) — a
,My Commission Expires_ '�7_�j My commission expires