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HomeMy WebLinkAboutNCC216488_FRO Submitted_20211201FINANCIAL 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. 1. Project Name Wooten Project 2. Location of land -disturbing activity: County Brunswick City or Township Supply Highway/Street Stone Chimney Rd SW Latitude 34.00967778 N Longitude 78.27527778 W 3. Approximate date land -disturbing activity will commence: September 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6. Amount of fee enclosed: $ 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 No Enclosed_ X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity Name Kelly Wooten E-mail Address wootenelec@atmc.net Telephone_ Cell # (910) 443-2078 Fax # (910) 754-7866 9. Landowner(s) of Record (attach accompanied page to list additional owners): All L's LLC (910) 443-2078 (910) 754-7866 Name Telephone Fax Number 199 Quilt Road SW 199 Quilt Road SW Current Mailing Address Current Street Address Supply NC 28462 Supply NC 28462 City State Zip City State Zip 10. Deed Book No. 4057 Page No. 1 191 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 or firm is a sole proprietorship the name of the owner or manager may be listed as the financially responsible party. All L's LLC wootenelec@atmc.net Name E-mail Address 199 quilt RD SW Current Mailing Address Current Street Address Supply NC 28462 City State Zip City State Zip Telephone9104432078 Fax Number9107547866 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 Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip Fax Number (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: Name of Registered Agent Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip Fax Number 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. Kelly Wooten Managing Member Type or print name Title or Authority Signature Date ------------------------------------------------------------------------------------------------------------------------------------ , a Notary Public of the County of State of North Carolina, hereby certify that 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 day of , 20 Seal Notary My commission expires