NCC220695_FRO Submitted_20220209

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
1. Project Name Wilkes County EMS Headquarters
2
3.
Location of land -disturbing activity: County Wilkes
City or Township Wilkesboro
Highway/Street Call Street Latitude 36,140039 Longitude-81.147410
Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, Industrial, institutional, etc.): Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.25 acres
6. Amount of fee enclosed: $ 600+1500=2,100 , The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900).
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 John Yates E-mail Address Iyates@wilkescounty. net
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wilkes County
Name Telephone Fax Number
110 North Street 110 North Street
Current Mailing Address Current Street Address
Wilkesboro NC 28697 Wilkesboro NC 28697
10.
City
State . Zip
City
Deed Book No. 657 Page No. 916
State
01
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.) ff the company or firm is a sole
proprietorship, the name of the owner or manager maybe listed as the financially responsible party.
Wilkes County
Name
110 North Street
Current Mailing Address
Wilkesboro NC
City State
[e-mail]
E-mail Address
110 North Street
Current Street Address
28697 Wilkesboro
Zip City
NC 28697
State Zip

Telepho
Fax Number
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
BREC, PA }[e-mail]
Engineering firm or other consultant E-mail Address
Justin Church, PE 336-844-4088
Individual contact person (type or print)
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.
John Yates
County Manager
Type or prira name Title or Authority
119AM VzWF_ - aa
Signs re Date
a Notary Public of the County of 1 s ,� r
[y �
State of North Carolina, hereby certify that _ ._ bV\Yt - OAKS appeared personally
before me this day and being duly sworn acknowledged thbt the above form was executed by him.
Witness my hand and notarial seal, this ZI(;;t
JENNIFER EDWARD5
Not �rr �ublic
Nort�iarolina
Wilkes County
day of 20ff ZZ
N otl ry
My commission expires P U