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HomeMy WebLinkAboutNCC223446_FRO Submitted_20221005FINANCIAL 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. Arbor Creek -Middle Creek Greenway 1. Project Name 2. Location of land -disturbing activity: County Wake City or Township Holly Springs Highway/Street Latitude35.6684 Longitude-78.8191 3. Approximate date land -disturbing activity will commence: 7/1 /2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Greenway 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.50 6. Amount of fee enclosed: $ 1200 The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00). 7. Has an erosion and sediment control plan been filed? Yes NoX Enclosed 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Tim Athy E-mail Address tim.athy@hollyspringsnc.gov Telephone (919) 577-3128 cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Town of Holly Springs Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip 10. Deed Book No. 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. Town of Holly Springs tim.athy@hollyspringsnc.gov Name E-mail Address PO BOX 8 128 S Main Street Current Mailing Address Current Street Address Holly Springs NC 27540 Holly Springs NC 27540 City State Zip City State Zip Telephone (919) 577-3128 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: 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. Tim Athy Town Engineer print na Signature Title or Authority - Z_ /I / Date 1, V �- a Notary Public of the County of Wcliz State of North Carolina, hereby certify that i , N\ 01VV1 A ' ,) -ti appeared personally before me this day and being duly sworn a6knowledghd that the above form was executed by him. Witness my hand and notarial seal, this C day of { � 20 Melanie R. Clark ,4 NotaryPublic Wake County, N.C. Notary M y Co is ion Expires 1�1�glZ.yr - ea My commission expires oc3