NCC230340_FRO Submitted_20230207

AL
YIOWNERSHIP
1f>EDIMIENTATION POLLUTION CONTROL ACT
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No person may initiate any land -disturbing activity on one or more acres as Covered by the Act before the 1-arid
d
and an acceptable erosion and
oii Environmer�tbon talol plari ualityave ubmtncompleted @M the completedform provLadto the appropriate
Quality section, N.C. Depart
Regional Office. (Please type or prinand, i the question is not applicable or the a -mail address or p one
number is unavafMable, place NA in the)
part A.
Back River WWTP Clarifier Project
1 . Pa ct Name—
Harnett Dunn
city or Township
2_ Location of land -disturbing activity; Couch+_ N35.2873 i8.636
5$() JW Edwards Lane Latitude(tleaR121 dsge,-eS)� Lo ng itud eoa.imal
Highwayltreet
Marsh 2023
_ Approximate date land -disturbing activity Ml comme„ce-_ — — -- \NTP Irnprovements
4 Purpose of development (residential. Commercial, industrial, institutional, etc.):_ 77
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)-,—'_---
00.00 The application fee of $100,00 per acre (rounded
6. Arnount of fee enclosed- —_ — lido#ior� fee is S900).
up to the next acre) is addressed N Dti=tia ceiling amount (Example; 8.10-acre app
Checks should be
7. Has an erosion and sediment control plan been filed? Yes [] Enclosed ICI
NO ❑
B. Person to contact should erosion and pediment control issues arse e�lschafer�dunn�no
n org
Steve Neuschafer, it Manager Email Address
Name
Phone; Office #
1 0-336-3500 Mobile #
Landowners) of Record (attach accompanied page to list additional owners),
City of Dunn — 910- 36-3500
Phone_ Office # hAobile #
Nsme
PO Pox 1065 401 East Broad Street
Current Street Address
Current Mailing Address Dunn 8334
Dunn 5 state Zip
s#ate zip city
City
678
pale rya,
014 Provide a copy of the most current deed.
10. Deed Soak No.

Part B.
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 fisted as the financially responsible party(ies).
1
City of Dunn
Company Name
PO Box 1065
Current Mailing Address
Dunn NC 28335
City State Zip
Phone: Office # 910-230-3500
[e-mail]
E-mail Address
401 East Broad Street
Current Street Address
Dunn NC 28334
City State Zip
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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State 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 regi gee to agent provide
ith
the authority to execute instruments for the Financially Responsible Party).
corrected information should there be any change in the information provided herein.
th' da and being duly sworn arKtiuvv1ruyou U1GI., - ----- . ---
before me �s y
Witness my hand and notarial seal, this -1 day of
.a��"��;rarrrali/rpgP,
lSe
0
0
1
Notary v
My commission expires d o—

Continued from Items 9 & 10 in Part A of the Financial Responsibilitylownership 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:
Phone: Office # Mobile #
Name
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 B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to fist all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 3 Name . E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Zip
Zip
Zip
Zip