NCC220120_FRO Submitted_20220107

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 NIA in the blank.)
Part A. Richland Creek Sewer Outfall Aerial Sewer Replacement
1.
Project Name
2.
Location of land -disturbing activity: County Guilford City or Township High Point
Highway/Street 5898 State Rd 1145 Latitude 35.944605 Longitude-79,910264
January 2022
3.
Approximate date land -disturbing activity will commence:
4.
Purpose of development (residential, commercial, industrial, institutional, etc.): Utilities
*Previously 5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18.8*
submitted for
6•
* $10 0 . 0 0
Amount of fee enclosed: $100 . The application fee of $65:ee per acre (rounded
18 acres in
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
March 2021.
Seeking 7
permit for 1
Has an erosion and sediment control Ian been filed? Yes No Enclosed X
semenplan
additonal
acre of LOD 8.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
for 18.8 total
Derrick Boone [e-mail]
Name E-mail Address
acres.
Previous fee
336-�883-3279 336-882-7074
Cell # Fax #
submitted:
Telephone
$1,170.
9.
Landowner(s) of Record (attach accompanied page to list additional owners):
City of High Point 336-882-4732
Name Telephone Fax Number
P.O. Box 230 5898 Riverdale Drive
Current Mailing Address Current Street Address
High Point, NC 27261 Jamestown, NC 27282
City State Zip City State Zip
10.
Deed Book No. Page No. Provide a copy of the most current deed.
*Deed for Eastside WWTP site where pipeline begins; it will be
Parts. installed in public easements.
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.
City of High Point Public Services [e-mail]
Name E-mail Address
P.O. Box 230 211 S Hamilton Street Suite 206
Current Mailing Address Current Street Address
High Point, NC 27261 High Point, NC 27261
City State Zip City State Zip
Telephone [phone] Fax Number NIA

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:
NIA
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Terry Houk
Type or print name /
Signature
Public Services Director
Title or Authority
Z 'Z
Date
I, a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn knowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of OkmeL , 20,2 1
Notary
L OL'n
NA J TURNr fj
Notary Public My commission expires` -J -
North Carolina
1(9 Guilford County

NOTICE
INCREASE IN SEDIMENTATION AND EROSION
CONTROL PLAN REVIEW FEE
$100.00 PER ACRE OR PART THEREOF
EFFECTIVE NOVEMBER 19, 2021
G.S. 113A-54.2(a) reads as rewritten:
"(a) An application fee of one hundred dollars ($100.00) per acre
of disturbed land shown on an erosion and sedimentation control plan or
of land actually disturbed during the life of the project shall be charged
for the review of an erosion and sedimentation control plan under this
Article."
This section becomes effective November 19, 2021 and applies to
applications submitted on or after that date.
15A NCAC 04B .0126 PLAN REVIEW FEE
(b) Each plan shall be deemed incomplete until the plan review processing
fee is paid.
(e) The plan review processing fee shall be based on the number of acres, or
any pant of an acre, of disturbed land shown on the plan.

FRI;
f '`City of High Point BANK OF AMERICA
{ 'CHARLOTTE, NC 282557i4889
Treasury Services Division 66-181530 P.O. Box 230
Nowni G.AOWWA51hTEAAAT Wk� CRY- High Point, NC 27261 12/0912021
VOID IF PRESENTED AFTER 60 DAYS
PAY One Hundred and 00/1 _0 Dollars $100.00
This Dishursemen Has wen jjppF0VCL1 as required by
the Local GovernnHwnt Budget and Fiscal Coalrol�Act.
PAY NC DEPT OF ENV QUALITY (47659)
TO THE 450 WEST HANES MILL RD STE 300
ORDER OF WINSTON SALEM NC 27105
,In 07 L4889lin 1:053000 L961: 000695L,636 L 2,11
Paid to: NC DEPT OF ENV QUALITY 4( 7659)
Descrlptlon PO # Inv #
120221 APP FEE 120221 APP
12/02/21 RICHLAND CREEK FEE
Total
Amount
$100.00
$100.00 1
Check # 714889
Deserlption Poll Inv #
NORTH CARC)LINA'S NTERNATtONAL ."tTy"'I
Amount I