NCC233524_FRO Submitted_20231129

(-71t3t411. 14
°�� APPLICATION FOR PERMIT FOR AFile Ies . 6 LAND DISTURBING ACTIVIl Y
x r % O Under the conditions set forth by LD Fee Review Pee
3 = _ The New Hanover County
1- E g s2 Soil Erosion and Sedimentation Control Ordinance Date Pd Date Pd
� -4il ��(�
Engineering Department The P
Applicant or Applicant's Agent: n e r (11 N , L,PP PPe' Ioe � .
Mailing Address: c'QJQX L 7 LJ Telephone Number: lip • lit-i ogl Fax Number:
Vo 4C Email Address: . he 11�evael� cvi_ nc,r�m
mud Acres of Land 'sturbance: , 41p �Sose of Development: �l 1YYII �v______ 1(VM
Description of Land Disturbance: Ole(ti 1- MO �UY 41 vtok me Address of Land Disturbance _ L11LP ( 3CC k-b&. Ud td- u Latitude: MAW Longitude.
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STATEMENT OF FINANCIAL RESPONSIBILITY
Land owtter(s) of record: Person or firm(s) financially responsible for the
land disturbing activity. If not a Note Carolina
resident, you MIDST have a N.C. ageng. (1Ust Below)
Name: III i t1 ' ' 10 / 1 Name: _ _ 110 1ko&e ' oU 1Ca.
it B c x -
Address: ki. 1 i►.it .A di tit l A !. t Lei' 'i. Li .i!tLl.A is A Address: QD boi 1S 1
1SHiq tbilW
Ci /State: ` 1 NG city/state: II C-
Zip Code: Z, Zip Code: 1-)1
Telephone Number: _ o • L)L ' - ?MA Telephone Number: °1110 LALl 3 3cpb,
Email: lifibZ t‘tleVIGlileetlyat421L:ot) . mber Email: helloOthf 91qc Q(Y1ixNuiber:
Location of deed(s) or instrument(s): County: ___New Ho \oVel' Boo, : ‘.,9(11,3 Page: . � 2 b
The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath.
(This form must be signed by the financially responsible person if an individual and by an officer, director, partner, attorney-in-
fact, or other person of authority to execute instruments for the financially responsible person if not an individual.) I agree to
provide corrected information should there be any change in the information provided herein.
Date: �) Tyra- t
l'annie (., . emitYl '.1SY1 Tine *,C___YY5dCt_
S:gnattre
-- = - . tom- - Countyof l���1 �(,� ►-�n �/c State of
T., NI /�t � /_n 4 '41v - a Notary Public of the
North Carolina, hereby certify that t
Va. r. appeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notary seal, this .z 2.- day of 45..E-4- _ , 20 02. '
• My caminlSstotf expires 1 \l• 3 Lz.f
Notary Nyllia Mann
SEAL NOTARY PUBLIC
New Hanover County, NC
My Commission Expires January 13, 2026
Fenoissiel3 to Erger on Land
I certify that 1 am authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on
the land in question in connection related to this permit application.
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Application . gnatur .nd Da
PLEASE COMPLETE ALL PORTIONS OF APPLICATION

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