NCC223897_FRO Submitted_20221206

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.
1. Project Name Ashe County Airport Water Line Extensions
2. Location of land -disturbing activity: County Ashe City or Township Jefferson
Ashe Central School Road
Highway/Street and Airport Road Latitude 36.430348 Longitude-81.431608
3. Approximate date land -disturbing activity will commence
November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.7 acres
6. Amount of fee enclosed: $ 130.00 . 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 V Enclosed
91
a
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Adam Stumb E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
See Attachment
Name Telephone
Current Mailing Address
City
10. Deed Book No.
Part B.
Current Street Address
State Zip City
State
Fax Number
Page No. Provide a copy of the most current deed.
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.
Ashe Co
Name
150 Government Circle, Suite 2500
Current Mailing Address
Jefferson NC 28640
City State Zip
[e-mail]
E-mail Address
150 Government Circle, Suite 2500
Current Street Address
Jefferson NC 28640
City State Zip

Telephone_ [phone] Fax Number [phone]
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
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:
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.
Adam Stumb County Manager
Type orprift-nam Title or Authority
i
�- Q/mil
Signature Date
I, �s �'� �,(� �_ (�{ (',L( a Notary Public of the County of &ke
State of North Carolina, hereby certify that AdCLW Sfuw'b 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 day of 20_
ASHLEY G HONEYCUTT Notary
MEY PUBLIC
County
MyCOMMteNetiwER� ! aC� (o My commission expires I ace/a�

Landowner(s) of Record
Ashe County [phone] [phone]
Name Telephone Fax Number
150 Government Circle, Suite 2500 639 Airport Road
Current Mailing Address Current Street Address
Jefferson NC 28640 Jefferson NC 28640
City
State
Zip City
NCDOT R/W - Routes 1583 and 1670
Name
P.O. Box 250
Current Mailing Address
North Wilkesboro NC
City
State
State
E
[phone] [phone]
Telephone Fax Number
801 Statesville Road
Current Street Address
28659 North Wilkesboro NC
Zip City
State
28659
0