HomeMy WebLinkAboutNCC223709_FRO Submitted_20221114Subject: Soil Erosion and Sedimentation Control Plan
Washington Medical
Beaufort County Tax Parcel Identification No: 5686-31-4573
Washington, Beaufort County, North Carolina
To whom it may concern:
As the current owner of Beaufort County Parcel Number: 5686-31-4573, as referenced
in Deed Book 2086, Page 435, of the Beaufort County Registry, please accept this letter
as permission from KAE Enterprises, LLC to allow White Construction and Design, LLC
the right to submit a Soil Erosion and Sedimentation Control Plan.
Sincerely,
Signature
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Printed Name
01RVAwiNG•- AWA 77KE-72,
Title
I, EA � , i k t rg 1 a Notary Public for the State of North Carolina,
County of Oci,+ do hereby certify that G« k C : We ; tze k
personally appeared before me this - C 7 day of ; e + 2022,
13
and acknowledged the due execution of the forgoing document. Witness my hand and
official seal.
My Commiss'io expir
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.
Project Name Washington Medical
2. Location of land -disturbing activity: County Beaufort City or Township Washington
Highway/Street Brown Street & Latltude(decimal degrees) 35.551667 Longltude(decimal degrees)-77.038056
Cowell Farm Rd.
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2 acres
6. Amount of fee enclosed: $ 200.00 . 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 R) No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eddie White E-mail Address whiteconstructionanddesignagmail.com
Phone: Office # 252-917-3070
Mobile # 252-917-3070
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KAE Enterprises, LLC
Name
4101 Sterling Trace Dr.
Current Mailing Address
Winterville NC 28590
City
State Zip
Phone: Office # Mobile #
4101 Sterling Trace Dr.
Current Street Address
Winterville NC 28590
City State Zip
10. Deed Book No. 2086 Page No. 435 Provide a copy of the most current deed.
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
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 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.
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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
White Construction and Design, LLC whiteconstructionanddesign(a)gmail. com
Company Name E-mail Address
1290 E. Arlington Boulevard, Suite 118 1290 E. Arlington Blvd., Ste. 118
Current Mailing Address Current Street Address
Greenville NC 27858 Greenville NC 27858
City State Zip City State Zip
Phone: Office # (252) 917-3070 Mobile # _(252) 917-3070
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)
Continued from Item 1 in Part B 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
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
State Zip
City State
Phone: Office #
Zip
City State
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Office #
Zip
City State
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Phone: Office #
Zip
City State
Mobile #
Zip
Zip
Zip
(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.
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I, r , a Notary Public of the County of 14
State of No Carolina, hereby certify that 1 geared personally
before me this day and being duly sworn ackno I dged that the above form was executed by him/her.
110
Witness my hand and notarial seal, this day of , 20 O
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