Loading...
HomeMy WebLinkAboutNCC220515_FRO Submitted_20220216FINANCIAL 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 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 NIA in the blank.) Part A. 1. Project Name Mira Branch Section Three 2. Location of land -disturbing activity: County_ Wayne City or Township New Hope Township Highway/Street South Beston Road SR 1719 River Basin: Neuse Latitude N 35.2994 Longitude W-77.8478 (Lat and Long given to 4 decimal places it XX.xxxx N,-YY.yyyy W. not XX xx'xx" N, -YY yy' yy" W) 3. Approximate date land -disturbing activity will commence:_ January, 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.), residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.6 Amount of fee enclosed: 400 The application fee of $6590 $100 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585). Has an erosion and sediment control plan been filed? Yes No Enclosed X Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name David A.Durham E-mail Address davidadurham(fsuddenlink.net Telephone Cell # (252) 468-3725 Fax# Landowner(s) of Record (attach accompanied page to list additional owners): David A. Durham 252 468-3725 Name Telephone Fax Number 677 S. Beston Road Current Mailing Address LaGrange NC 28661 City State Zip Current Street Address City State Zip 10. Deed Book No. 1208 Page No. 131 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): David A. Durham Name 677 S. Beston Road Current Mailing Address LaGrange NC 28551 City State Zip Telephone 919 609-1661 davidadurham suddenlink.net E-mail Address Current Street Address Fax# City 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 Current Mailing Address City State Zip Telephone E-mail Address Current Street Address City State Zip Fax# (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 Current Mailing Address City State Zip Telephone E-mail Address Current Street Address City State Zip Fax# 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 by any change in the information provided herein. David A. Durham Type or ' t name igna ure Owner Title or Authority 12--15-2021 Date I, Doris S. McFatter a Notary Public of the County of Wayne State of North Carolina, hereby certify that David A. Durham appeared personalty before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this 15th x```\ S 1imeF�r��,�� N87XRY PUBLIC CO fitil _ day of Dec. 12021 J, we, Notary Doris 5. IVIEFatter My commission expires January 13't'. 2026 .