Land Disturbance ApplicationAPPLICATION FOR PERMIT FOR A lAND DISTURBING ACTIVITY
Under the conditions set forth by
The New Hanover County
Soil Erosion and Sedimentation Control Ordinance
File# __ _
LDFee Review Pee
Date Pd __ Date Pd __ _
Engineering DepartmentApplicant or Applicant's Agent: __ K _h_a _li _d_S_a_le_h ___________________________ _Mailing Address: 3811 Cotto nwoo d Drive Telephone Number: 919-599-0301 Fax Number: _____ _Durham, NC 27705 Email Address: ksale h33 50@aol.com ---------------------Tot al Acres of Land Disturbance: _1._ _3 ___ Purpose of Development: New commercial constructionDescription of Land Disturbance: Demo all existing structures, etc. {in phases) and prepare site for new construction of convience store w/ fuel pumps
Address of Land Disturbance 7650 Market Street Latitude: 34.283682 Longitude: -77.807970
Land owner(s) of record:STATEMENT OF FINANCIAL RESPONSIBILITYPerson or firm(s) financially responsible for the land disturbing activity. If not a North Carolina resident, you MUST have a N.C. agent. (List Below)Name: __ A_n_n_S_._D_o_w_n_i_n=g __________ _ · Address: 8044 Bald Eagle LaneCity/State: Wilmington, NC
Name: Khalid Saleh Address: 3811 Cottonwood Drive City/State: Durham, NC
Zip Code: 28405-9303 Zip Code: _2_7_7_0_5 _______________ _ Telephone Number: _9_1_0-_5_2_0-_3_1_3_3 _________ Telephone Number: _9_1 _9_-5_9_9_-0_3_0_1 __________ _ Email: adowning@reagan.com FaxNumber _____ �Email: ksaleh3350@aol.com FaxNumber: ------Location of deed(s) or instrument(s): County: New Hanover County Book: 1214 & 1646 Page: _44_7_&_1_384 ___ _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, attomey-infact, 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: /2 N�·°. Nlime Khalid Sale h Title -f-_.�_'t!�/>-=l..-�"-'--'l/. ...... 1: __ _S1gnature � z:;> .,
I, i.x2 *'"' %" ti I tlL, North Carolina, hereby certify that a Notary Public of the County of l> 1 f rkt{MN State of
6 bl\ I ;-o �a, \v �appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my,)j��s l £ day of 1:)e... Gt. ::\11\�f-.:CNotary�� My commission expires
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Permi;;"on to�.! �n LandI certify that I .am authorized to grant and do in fact grant permission to the Erosion Control Inspector and his agents to enter on · on related to this permit application.
0 Application Signature and Date
PLEASE COMPLETE ALL PORTIONS OF APPLICATION
1.391.48