NCC233471_FRO Submitted_20231127

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Erosion Control Permit Application "5 116fs m 5s 51�rein NC;n1af.7.51 T
Please use this form when the Developer and Builder are not the same Ftonc.3t2 ar MG)le 7133
Far(306,1 M-VEIZ
ftnancially responsible party/person and will be less than one (1) acre of
land disturbance on any one (1) lot_
Logs)to be Developed lnforrnation
Sae Acidrex;: , il7<zp16,. (/?_ I► -
Subdivision Name: 41)4(8Al j 4/16-Se --' -7—
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Anticipted Olin DP Coititrutli0r1 iiy: Start 11/ 3/L-1 Completions: 11/J 24
"'Complete the LOT INFORMATION TABLE for each lot ID be developed;ensure that the appropriate drainage patter type is
denoted_ Attach a corresponding.existing platted survey for each kt with your application. *etc If nut,your permit
application may not be accepted for review_
Financially Responsible FactylP+ersm
Name_ - S1 rt&c 1 c,r ')n C _
Address* I/9 6V1rllrr,. frLtcc
OtyIState,Zp: J of_4h75v) IL, IUC. 2.702_3 oinks Nor*._
Mope phone; DC_772 a',L" Erma address: p2;5 6.5-€ J mcre J •Cos,.,
My sigtaucu learnt)signife; I am the owneriiinanclally responsible party fur job sibs caw:came with the Erosem Dadra;Ordinance
as outlined in Chapter. Sec liuh$,4 nl the Unified pevelagrnent Ordinances(UDOE 9f the Cily of ' iInslr-Sae!n/Fc(syth County or
Article IV of thn t!DO rif the Also of Clernrnons.Town of Leviisv&.or Town of Waikerthwn. I hereby ack2 1cdge that iho BeA
Managentasi Practices annotated on the attached szcerch plan must be pvopesly installed and enaintainod 10 reiarn tool within the
constructed tot
i uik er5tand that rf the total disfiabad anaa for any reason becomes greater than one a e on anyone(1}kit,a prode%sioneliy designed
and sealed Esocion Control Pion sill ie required to be submitted and approved before the start of Its?ianc disturbing activity on tlxe lot. I
further acknowIedgetiat City Inspection's siaf rr..ay refuse 10 make blrhng inspections aid the Eroeiurr C061rol nrision rr,:iy issue
Nolioes of ViUkiii0u, Stop Work Orders aneior Civil Penalty f.ssessux r'Is for failure la comply with Eros,Oi Conti requirements_
4i�. qYi CSC ._
n ib(e Person Signature of Wand ly Fiesponsibie Person
TO BE COMPLETED$Y CITY STAFF ONLY-
Date of A pSr atio n Srutxnitial:
Permit Plumber._