NCC223047_FRO Submitted_20220826

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. WDP#2: Patton Avenue Water Distribution Project WC-17-18-003
1. Project Name
2. Location of land -disturbing activity: County Buncombe City or Township Asheville
Highway/Street Patton Avenue Latitude 35035'12.75"N Longitude 82035'23.19"W
3. Approximate date land -disturbing activity will commence_ November 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public utility Water
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.1
6. Amount of fee enclosed: $ 585.00 . 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 x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mr. Chad Pierce, PE E-mail Address [e-mail]
Telephone [phone] Cell # Fax it [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Asheville (easement)
[phone] [phone]
Name
Telephone Fax Number
PO Box 7148
161 South Charlotte Street
Current Mailing Address
Current Street Address
Asheville, NC 28802
Asheville, NC 28801
City State .Zip
City State Zip
10. Deed Book No. See attachments page No.
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.
City of Asheville Water Resources Department
NIA
Name
E-mail Address
PO Box 7148
161 South Charlotte Street
Current Mailing Address
Current Street Address
Asheville, NC 28802
Asheville, NC 28801
City State Zip
City State Zip
Telephone [phone] Fax Number [phone]

2. (a) It the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NIA
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:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State .Zip
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 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.
David Melton
Type t`"13rir'111;1
me
Signature
Director of Water Resources
Title or Authority
Date
I, ?O-Mt✓. LCI, 01 LS V i , a Notary Public of the County of llau."140
State of North Carolina, hereby certify that appeared
appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this /`7 day of '�y'OC 20 r2_1
E
AMELA CARO "�`"Notary Publc IRVIN otary
wWaunty, North Carolina %S>✓
June ©�, 2t?25pires My commission expires j VY)42_ r G1