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HomeMy WebLinkAboutNCC232248_FRO Submitted_20230727 Check if this project is ARPA-funded ❑ Attach a copy of the Letter of Intent to Fund 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, including any activity under a common plan of development of this size as covered by the NCGO1 permit, 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. 1. Project Name Subdivision for Rudy Eduardo Gallegos `If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e g , SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Robeson City or Township Lumberton Hwy. 72 & Saxon Ave. 34.602932 LongRude decimal degrees) -78.980632 Highway/Street Latltude(decimai degrees) 3 Approximate date land-disturbing activity will commence 7/15/23 4 Purpose of development(residential, commercial, industrial, institutional, etc.) Residential Subdivision 5 Total acreage disturbed or uncovered (including off-site borrow and waste areas) 18 Acres 6 Amount of fee enclosed: $ 1 ,800.00 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 E No El 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Rudy Eduardo Gallegos E-mail Address radV CACW iCC Z.j fj I eon Phone: office# Mobile# 910-258-5523 9 Landowner(s) of Record (attach accompanied page to list additional owners) Rudy Eduardo Gallegos 910-258-5523 Name Phone: Office# Mobile# 1304 Saxon Avenue 1304 Saxon Avenue Current Mailing Address Current Street Address Lumberton NC 28358 Lumberton NC 28358 City State Zip City State Zip 10 Deed Book No. 2184 Page No. 101 Provide a copy of the most current deed. (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. Rudy Eduardo Gallegos Owner Type or print name Title or Authority Signature Date I, u _u diva J J(c a Notary Public of the County of he >/1/L, State of North Carolina, hereby certify that 6t 1t echo do 4 `u►E.tc appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her Witness my hand and notarial seal, this n°l /'"-day of_____) , 20 ,E O•_• TA •••. � z_i/S4/9 Lk/41,A67' otary Seal Q: \`O R7•••.9 ..My Comm.Expires _ My commission expires(./ 1�12 4 ' / �,* 7.13 • Ugh oN•coy 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 State Zip Phone: Office# Mobile# Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile#