NCC233190_FRO Submitted_20231116

--HENDEPS �'UNTY�;.
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
CITY OF HENDERSONVILLE
SOIL EROSION AND SEDIMENTATION CONTROL
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 completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, 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 The Outpost PIN#: 9546-81-7720
2. Location of land-disturbing activity: County Henderson City or Township Hendersonville
Address of Project: 227 Outpost Lane Latitude 35.243030 Longitude-82.522820
3. Approximate date land-disturbing activity will commence: ASAP
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Camp
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 17.0
6. Amount of fee enclosed: $6,900 Already paid . Fee Schedule FY 2018-2019 is available on
Water Resources at link https://www.hendersoncountync.gov/waterresources/page/approved-
fees-fy-2018-2019-0.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mike Lovoy, P.E. E-mail Address [e-mail]
346 Merrimon Avenue 346 Merrimon Avenue
Current Mailing Address Current Street Address
Asheville NC 28801 Asheville NC 28801
City State Zip City State Zip
Telephone[phone] Cell#
9. Landowner(s) of Record (attach accompanied page to list additional owners) NOTE: Must match
Henderson County Courthouse - Land records information or provide a recorded deed:
Crab Creek Development, LLC [phone]
Name Telephone Fax Number
213 S Church Street 213 S Church Street
Current Mailing Address Current Street Address
Hendersonville NC 28792 Hendersonville NC 28792
City State Zip City State Zip
City of Hendersonville FRO.doc Revised 6-19-2018

10. Deed Book No.3903 Page No.352 Provide a copy of the most current deed.
Part B.
1. Person(s) or firms who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet) NOTE: The signature of a
corporation, or LLC must be a listed member on the formation documents on file with the
state office at https://www.sosnc.gov/search!index/corp.
Crab Creek Development, LLC [e-mail]
Name E-mail Address
213 S Church Street 213 S Church Street
Current Mailing Address Current Street Address
Hendersonville NC 28792 Hendersonville NC 28792
City State Zip City State Zip
Telephone[phone]
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(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 Parry's a Corporation, give name and street address of the Registered Agent:
(Rare)
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
City of Hendersonville FRO.doc Revised 6-19-2018

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.
Dan Collins Owner
Type or print name Title or Authority
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ignature ' Date
I, 64-1 S , Dell-{-On , a Notary Public of the County of U-�-he� �C Ccy
State of North Carolina, hereby certify that 'Dekn CO11 l AS 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 21 day of aanb . , 20 a3
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City of Hendersonville FRO.doc Revised 6-19-2018