NCC222605_FRO Submitted_20220725

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Jackson County Recreation Center -Aquatics
2. Location of land -disturbing activity: County Jackson City or Township CulloWhee
88 Cullowhee Mtn Road 35.290570-83.180790
Highway/Street Latltude(decimal degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.01
6. Amount of fee enclosed: $ 800 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Z No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tony Elders E-mail [e-mail]
Phone: Office # 828-631-2284 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jackson County [phone]
Name Phone: Office # Mobile #
401 Grindstaff Cove Rd, Suite 107 401 Grindstaff Cove Rd, Suite 107
Current Mailing Address Current Street Address
Sylva NC 28779 Sylva NC 28779
City State Zip City State Zip
10. Deed Book No. 834 Page No. 230 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Jackson County - Don Adams
Company Name
401 Grindstaff Cove Rd, Suite 107
Current Mailing Address
Sylva NC 28779
[e-mail]
E-mail Address
401 Grindstaff Cove Rd, Suite 107
Current Street Address
City State Zip City State Zip
Phone: Office # [phone] Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Don Adams
County Manager
Types ovnrint name Title or Authority
L. z / Z
Signature Date
I, k4k-A 1 6. TtyCwL a Notary Public of the County of MaAAVOUI
State of North Carolina, hereby certify that _ an , appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of 4ril 20 _
Seal tNOTAgy '-"
? NY
OOMYIS"M EXPIRES
s= V?y2n�
G
CO
Nota
My commission expires 44

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
Phone: Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
E-mail Address
State Zip
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
E-mail Address
Zip
State Zip
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

JACKSON COUNTY, NC 15531 - NCDEQ-DIV OF ENERGY,MINERAL AND LAND RESOURCES Check No. 281235
INVOICE
NO.
PO '
NUMBER
DESCRIPTION
AMOUNT
04/11 /2022
JACKSON CO RECREATION CTR - AQUATICS - EROSION CONTROL PERMIT
800.00
PAYEE SHOULD DETACH STUB AND DEPOSIT CHECK AT ONCE
TOTAL
$800.00
Gq.gON CO' Jackson County
401 Grindstaff Cove Rd.
U, Sylva, NC 28779
o�� A 0���
PAY EIGHT HUNDRED AND 00/100 DOLLARS
WELLS FARGO BANK, N.A.
11-24/1210 CHECK NO. 281235
DATE
04/18/2022
$800.00 ";"
VOID AFTER 90 DAYS
This disbursement has been approved as required by
the Local Government Budget and Fiscal Control Act.
TO NCDEQ-DIV OF ENERGY,MINERAL AND LAND
THE RESOURCES
ORDER 1612 MAIL SERVICE CTR-STORMWATER BILLING
OF RALEIGH, NC 27699-1617
AUTHORIZED SIGNATURE(S)