NCC230106_FRO Submitted_20230113

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. Hammocks Beach State Park - Phase 1
1. Project Name
2. Location of land -disturbing activity: County Onslow City or Township Swansboro
Highway/Street Hammocks Beach Road Latitude 34.6800 Longitude-77.1444
3. Approximate date land -disturbing activity will commence: Winter 2020/Spring 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10 AC +2 AC
6. Amount of fee enclosed: $ 5 +$200 . 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 Steven J. Miller, PE E-mail [e-mail]
Telephone [phone] cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NC State Parks/DNCR 919.707.9361
Name Telephone Fax Number
1516 MSC 121 West Jones Street
Current Mailing Address Current Street Address
Raleigh NC 27699-1615 Raleigh NC 27603
City State Zip City State Zip
10. Deed Book No. 4294 Page No. 277 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.
NC Division of Parks and Rec. [e-mail]
Name
1615 MSC
Current Mailing Address
Raleigh NC 27699-1615
City
E-mail Address
121 West Jones Street
Current Street Address
Raleigh NC 27603
State Zip City
Telephone [phone] Fax Number
State
Zip

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 E-mail Address
Current Mailing Address
City State Zip
Telephone
Current Street Address
City
Fax Number
State Zip
(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 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.
Jerry Howerton Chief of Design and Construction
T pe or print n e Title or Authority
gnature Date
a Notary Public of the County of
State of North Carolina, hereby certify that ,)2rr � A. JyJ�-}oY\ appeared
personally before me this day and being duly s, rn acknowledged that the above form was
executed by him. L
Witness my hand and notarial seal, this day of dA4&YE, 20
ry
HW& RuMb� ota
Se NOTARY PUBUG
WAKE COUNTY, N.C. My commission expires 7 C� o� v