NCC215577_FRO Submitted_20211011

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 Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. Derita Branch SanitarySewer Improvements Project Phase I
1. Project Namep
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street N Tryon St Latitude 35.251971 Longitude-80.809646
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .19
6. Amount of fee enclosed: $ 130 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mac McClanahan E-mail Address [e-mail]
Telephone [phone] Cell # 704-995-7489 Fax # N/A
0
Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached See Attached
Name Telephone
See Attached See Attached
M
Fax Number
Current Mailing Address Current Street Address
See Attached See Attached
City State Zip City State Zip
10. Deed Book No. See Attached Page No. See Attached Provide a copy of the most current deed.
Part B.
1, Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
City of Charlotte [e-mail]
Name E-mail Address
5100 Brookshire Blvd 5100 Brookshire Blvd
Current Mailing Address Current Street Address
Charlotte, NC 28216 Charlotte, NC 28216
City State Zip City N/AState Zip
Telephone [phone] Fax Number

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:
N/A
N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
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:
N/A
N/A
Name of Registered Agent
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A Fax Number N/A
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.
Joseph C. Wilson Charlotte Water Chief Engineer
Ty epr pri name
ZOII
SiMature
Title or Authority
Date
t l
n r."V4A a Notary Public of the County of
f)
State of North Carolina, hereby certify that AY ;. _- ;_ `'a , jj' appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
4,
Seag3: NOTARY
PUBLIC
C)us G'0
�®
I
1 "^• Tr
9 day of J 1 , >w' .._ 20 �JI
ZC
Notary
My commission expires ' t