NCC233501_FRO Submitted_20231128

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 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 andior fax information unavailable, place NlA in the blank.)
Part A.
1. Project Name 9760 Lissara Camp Ct.
2. Location of land-disturbing activity: County_Forsyth City or Township_Winston
Salem
Highway/Street_ Lissara Camp CI_ Latitude_36.1115 Longitude_-80.4516_ -
3 Approximate date land-disturbing activity will commence:_11-30-23
4 Purpose of development (residential, commercial, industrial, institutional, etc.)• Residential_
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas)_.25_
6. Amount of fee enclosed: S 65 . The application fee of $65.00 per acre (rounded up
to the next acre)is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
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
Narne_Bryan Elliott E-mail Address_elliotbryan©gmail corn
Telephone Cell#_339-345-3551_ Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
B Elliott Enterprise Inc. _336-345-3551
Name Telephone Fax Number
_2725 Rothgeb 2725 Rothgeb dr
Current Mailing Address Current Street Address
_Raleigh_ _NC 27609
City State Zip City State Zip
0. Deed Book No. 3505 Page No_3824 Provide a copy of the most current deed.
Part B.
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):
_B Elliott Enterprise Inc elliolbryan@gmail corn
Name E-mail Address
2725 Rothgeb dr _ 2725 Rothgeb Dr
Current Mailing Address Current Street Address
Raleigh NC 27609
City State Zip City State Zip

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