NCC221306_FRO Submitted_20220405

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.
Project Name Connector Road
2. Location of land -disturbing activity: County Moore
City or Township Carthage
Highway/Street Dowd Street Latitude 35.342 Longitude-79.420
3. Approximate date land -disturbing activity will commence: Jan/Feb 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Government
previous approval for 2.2 acres
additional 1.3 acres being
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.5 added.
3 x $65 previously paid for a total of $195, additional 1 acre being added to review (post fee increase) for total of $295
6. Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Richard Smith E-mail Address [e-mail]
Telephone [phone] ext 4027 Cell # 910.947.6363
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
County of Moore
Name
PO Box 905
Current Mailing Address
910.947.6363
Telephone Fax Number
1 Courthouse Square
Current Street Address
Carthage NC
28327
Carthage
NC 28327
City State
Zip
City
State Zip
10. Deed Book No. 3289
Page No.
568
Provide a copy of the most current deed.
Part B.
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.
County of Moore
Name
PO Box 905
Current Mailing Address
Carthage NC 28327
City State Zip
[e-mail] & [e-mail]
E-mail Address
1 Courthouse Square
Current Street Address
Carthage NC 28327
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:
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
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.
Wayne Vest
Type or print name
ature
Moore County Manager
Title or Authority
/- � o
Date
I, m oyi\ �� �l� �J� , a Notary Public of the iCounty of
State of North Carolina, hereby certify that o ri �-1�es �- " "1 M4Kng8' appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my handa�I�q�f�his
Notary Public
Moore County
Seat% -P.
day of ;JLtY iLIQY �( , 202'
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Nota
My commission expires