NCC221034_FRO Submitted_20220315

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. Franklin County E911
1. Proiect Name
2. Location of land -disturbing activity: County Franklin City or Township Louisburg
Highway/Street 285 T Kemp Road Latitude 36.09361 Longitude 78.31972
3. Approximate date land -disturbing activity will commence: 06/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Civic
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3
6. Amount of fee enclosed: $ 195 . 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
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Blake Hall E-mail Address Blake. [e-mail]
Telephone [phone] cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Franklin County
[phone]
Name
Telephone Fax Number
113 Market Street
113 Market Street
Current Mailing Address
Current Street Address
Louisburg NC
27549 Louisburg NC 27549
City State
Zip City State Zip
10. Deed Book No. 998
Page No. 522 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.
Franklin County
[e-mail]
Name
E-mail Address
113 Market Street
113 Market Street
Current Mailing Address
Current Street Address
Louisburg NC
27549 Louisburg NC 27549
City State
Zip City State Zip
Telephone [phone]
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:
N/A
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
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.
K,mb^ c3. _Dein
Type or Tint nd
ignature
Cow,- v.a iel-
Title or Authority
55—ate
I, P& 13 AV- , a Notary Public of the County of Vaa, Y-U%O
State of North Carolina, hereby certify that & ['*Yl ec i 4 G NILM 1 b e-'N appeared
personally before me this day and being duly sworn a owledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of �Jo , 2d
A 113.
Na rgq Notary
Seal
4 My commission expires i
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