NCC230783_FRO Submitted_20230322

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. (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.
1. Project Name Dye Creek Greenway
2. Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street
Johnson Dairy Road to Bellingham Park Latitude 35.535703Longitude -80.798533
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreation
14.46 - ORIGINALLY PERMITTED
0.93 - ADDITIONAL DENUDELI
5. Total acreage disturbed or uncovered (Including oft -site borrow and waste areas):15.39-TOTAL DENUDED AREA
6. Amount of fee enclosed: $ ss FOR ADDITIONAL ACREAGE) 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 Jonathan Young E-mail [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Town of Mooresville
704-799-4065 704-662-6298
Name
Telephone Fax Number
413 North Main Street
413 North Main Street
Current Mailing Address
Current Street Address
Mooresville NC
28115
Mooresville NC 28115
City State
Zip
City State Zip
10. Deed Book No.
Page No.
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.
Town of Mooresville
[e-mail]
Name
E-mail Address
413 North Main Street
413 North Main Street
Current Mailing Address
Current Street Address
Mooresville NC
28115
Mooresville NC 28115
City State
Zip
City State Zip
Telephone [phone]
Fax Number 704-662-6298

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 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
State Zip City
Telephone Fax Number
State Zip
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.
Randall W. Hemann
Type or print name
Signature
Town Manager
Title or Authority
1 /�C/2p2Z
Date
I, a Notary Public of the County of Vovla
State of North Carolina, hereby certify that Randall W. Hemann
personally before me this day and being duly sworn acknowledged that the
executed by him.
appeared
above form was
Witness my hand and notarial seal, this Sty day of _ J an�a+r�j 20 27-
Seal
Nota
My commission expires ) 1 1 2-Z
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