NCC240212_FRO Submitted_20240126

1 La-UN xc.,✓v 1r.w/r1NANCIAL RESPONSIBILITY/OWNERSHIP FORM
CATAWBA COUNTY CODE OF ORDINANCES, CHAPTER 16 ARTICLE V
SOIL EROSION AND SEDIMENTATION CONTROL
No person may initiate any land-disturbing activity on one or more acres as covered by the Ordinance before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Catawba County
Utilities and Engineering Department. (Please type or print, and if question is not applicable,please N/A in the blank)
PART A
1. Job Name IRIDES-STORAGE
2. PIN or 911 Address 1374207575927
3. Purpose of development (residential, commercial, industrial, institutional,etc.)ICOMMERCIAL
4. Approximate soil disturbance date 111/15/23
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas) 11.7o
6. Has an erosion and sedimentation control been filed? r Yes r No I` Attached
7. If you have an Erosion Control billing account, would you like this to be billed? r Yes V No
Account Number INA
PEOPLE
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name (JOSH WILKIE E-mail address [[e-mail]
Telephone j828-754-6431 Cell # I Fax# I
9. Landowner(s)of Record (attach accompanied page to list additional owners)
Name IDANA D. ISENHOUR Telephone I Fax # f
Current Mailing Address 15252 LEE CLINE ROAD
City ICONOVER State INC
Zip 128613
Current Street Address 'SAME
City State I Zip I
10. Deed Book No. 12241 Page No. 10003
PART B
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a comprehensive list
of all responsible parties on attached sheet):
Name IDANA D ISENHOUR E-mail address I
Current Mailing Address 15252 LEE CLINE ROAD
City 'CONOVER State INC Zip 128613

.0 front Street Address (SAME
City i State J I
Zip
Telephone I Fax# I
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 [NA E-mail address J
Current Mailing Address I
City I State I Zip I
Current Street Address I
City 1 State I
Zip
Telephone I Fax# I
2. (b) If the financially responsible party is a Partnership or other person engaging in business under assumed name,
attach a copy of the Certificate of Assumed Name. If the financially responsible party is a Corporation, give name
and street address of the Registered Agent:
Name I E-mail address I
Current Mailing Address 1
City I State I Zip I
Current Street Address I
City I State I I
Zip
Telephone I Fax # I
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.
JDicc Ti 5 e n h •
T or Print N e Title of Authority
...- 16 / 24 /2..3
ignature Date
I, G(aux, , a Notary Public of the Countyof
Carolina,herebycertifythat� �� ��} �� State of North
POf( 0 -1 lYlour appeared personally before me this day and being duly
sworn acknowledge that tkvolinom f?rm was executed by him.
.`' OE DO, '#, r
Witness my hand and' ry*ie.al bur�- W day of OCkdOCK ,2035
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Seal �4TAgy• .
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' PUBL\C
My Commission expires 0 l 1 5/ �.o ag
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