NCC232421_FRO Submitted_20230818

FINANCIAL RESPONSIBILITY/O`"'NERSHIP 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 Environment and Natural Resources. (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: Runway 11-29 Extension and Turnarounds, Runway Rehabilitation and PAPI
Replacement
2. Location of land-disturbing activity: County Hyde City or Township Engelhard
Highway/Street 470 Airport Road Latitude 35°33'42.26"N Longitude 75°57'20.52"W
3. Approximate date land-disturbing activity will commence: Spring 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12
6. Amount of fee enclosed: $ 780.00 . 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 Jane Hodges E-mail Address [e-mail]
Telephone [phone] Cell# 252-943-4113 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hyde County _ 252-926-4372 252-926-3701
Name Telephone Fax Number
P.O. Box 188
Current Mailing Address Current Street Address
Swan Quarter NC 27885
City State Zip City State Zip
10. Deed Book No.103 Page No.091 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Kris Noble knoble(a,hydecountync.gov
Name E-mail Address
30 Oyster Creek Rd.
Current Mailing Address Current Street Address
Swan Quarter NC 27885
City State Zip City State Zip
Telephone [phone] Fax Number 252-926-3701

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 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.
Kris Noble County Manager
Type or prin ame T le or Authority
ftoont Afriatt,
f )_IV a.
3,a00
Signature D.4
I, J♦ , a Notary Public of the County of 1
ir.�State of North Carolina, hereby certifythat (,A7014, appeared
personally before me this day and being d ly sworn acknowledged that the above form was
executed by him. !/
Witness my hand and notarial seal, this day of , 20 o20
, y4(re%
TA IAN
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Seal i
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� , My commission expires ✓''/d7"•o2002.2