NCC233195_FRO Submitted_20231025

Check if this project is ARPA-funded ❑
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 Briar Creek Stream Enhancement
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
N/A
2. Location of land-disturbing activity: County Mecklenburg City or Township Charlotte
Lila Wood Circle 35.161253 -80.844732
Highway/Street Latltude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:June 1 , 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Stream Restoration
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '98
6. Amount of fee enclosed: $2OO . 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Crystal Goode E-mail Address [e-mail]
Phone: Office# [phone] Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Mecklenburg County [phone]
Name Phone: Office# Mobile#
600 East 4th Street 600 East 4th Street
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City State Zip City State Zip
10. Deed Book No.04951 Page No.0038 Provide a copy of the most current deed.
Deed Book No.12023 Page No. 054

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).
Mecklenburg County [e-mail]
Company Name E-mail Address
600 East 4th Street 600 East 4th Street
Current Mailing Address Current Street Address
Charlotte, NC 28202 Charlotte, NC 28202
City State Zip City State Zip
Phone: Office# [phone] 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 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)

(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.
Leslie Johnson Deputy County Manager
Ty e or ' t name Title or Authority
o t m a.,,,I 2_0 2-3
ign ure Date
I, -1()r 1 SS ECiS6Th , a Notary Public of the County of nYC��ehbt�r
State of North Carolina, hereby certify that Les lye Johns orl 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 la day of alai a , 20 (2 3
OiLiA)A-e„
Arlissa Eason Notary
NOTARY PUBLIC III
Mecklenburg County My1 al ai J aoa-�
North Carolina commission expires
My Commission Expires December 21.2027

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:
Jenkins and Gwynn Ravenel
Name Phone: Office # Mobile#
405 Moncure Drive 405 Moncure Drive
Current Mailing Address Current Street Address
Charlotte, NC 28209 Charlotte, NC 28209
City State Zip City State Zip
Deed Book No.4704 Page No. 0721 Provide a copy of the most current deed.
Landowner 3 of Record:
Lee and Laurel Richardson
Name Phone: Office # Mobile#
417 Moncure Drive 417 Moncure Drive
Current Mailing Address Current Street Address
Charlotte, NC 28209 Charlotte, NC 28209
City State Zip City State Zip
Deed Book No.8574 Page No. 189 Provide a copy of the most current deed.
Landowner 4 of Record:
James and Kristi Warren
Name Phone: Office# Mobile#
5335 Lila Wood Circle 5335 Lila Wood Circle
Current Mailing Address Current Street Address
Charlotte, NC 28209 Charlotte, NC 28209
City State Zip City State Zip
Deed Book No.28038 Page No.753 Provide a copy of the most current deed.
Landowner 5 of Record:
Selwyn Grove Homeowners Association
Name Phone: Office# Mobile#
5334 Lila Wood Circle 5334 Lila Wood Circle
Current Mailing Address Current Street Address
Charlotte, NC 28209 Charlotte, NC 28209
City State Zip City State Zip
Deed Book No. 12980 Page No.729 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 6 of Record:
Susan Anderson
Name Phone: Office# Mobile#
3911 Selwyn Avenue 3911 Selwyn Avenue
Current Mailing Address Current Street Address
Charlotte, NC 28209 Charlotte, NC 28209
City State Zip City State Zip
Deed Book No.5368 Page No. 0715 Provide a copy of the most current deed.
andowner 3 of Record:
e Phone: Office# Mobile#
Current -fling Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a co. of the most current deed.
Landowner 4 of Record:
Name Phone: a fice# Mobile#
Current Mailing Address ► , rent Street Address
City State ZIA City State Zip
Deed Book No. Pas- No. ' ovide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailin. A ddress Current Street Address
City State Zip City State Zip
Do •d Book No. Page No. Provide a copy of the most current d--d.