NCC222052_FRO Submitted_20220604

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Torrence Creek Tributary 11 Greenway
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township Huntersville
Highway/Street Rosewood Meadow Ln Latitude 35.410074 Longitude-80.867438
3. Approximate date land -disturbing activity will commence: April 5, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Greenway
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of fee enclosed: $ 390.00 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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 $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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
Jennifer Brooks E-mail Address [e-mail]
Telephone [phone] cell # 980.445.8724 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Huntersville 704.766.2220
Name Telephone Fax Number
P.O. Box 2879 105 Gilead Road
Current Mailing Address Current Street Address
Huntersville, NC 28070 Huntersville, NC 28078
City State Zip City State Zip
10. Deed Book No. 11444 Page No. 496 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.
Mecklenburg County [e-mail]
Name
3205 Freedom Drive, Suite 6000
Current Mailing Address
Charlotte, NC 28208
City
E-mail Address
3205 Freedom Drive, Suite 6000
Current Street Address
Charlotte, NC 28208
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:
Name
Current Mailing Address
city
State Zip
E-mail Address
Current Street Address
city
Telephone Fax Number
State Zip
(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 State Zip
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:
Dewberry Engineers Inc [e-mail]
Engineering Firm or other consultant E-mail Address
Tristan M. McMannis, PI_.A 704.264.1233 704.509.9937
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 attomey-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.
Jennifer Brooks
Type or print name
lighj signedJennfer Brooks
Jennifer Brooks Dated 02.0121y1232:33 05'00'
Signature
Karla M. Garris
Project Manager
Title or Authority
January 21, 2021
Date
a Notary Public of the County of
Mecklenburg
State of North Carolina, hereby certify that Jennifer Brooks appeared personally
before me this day and being duly sworn acknowledged that the abo)a� form was executed by him.
Witness my hand and notarial seal, this 21 st day of
Seal
5 1
2021
My commission expires March 7, 2023