NCC233715_FRO Submitted_20240104

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 Machine Welding Outfall
*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).
SRP-W-ARP-0033
2. Location of land-disturbing activity: County Harnett City or Township Dunn
SR 1790, Hwy 301 35.2973 -78.6366
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Sewer Outfall
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 9.75 AC
6. Amount of fee enclosed: $ 1 ,000 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Steve Neuschafer, City Manager E-mail Address [e-mail]
Phone: Office# [phone] Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Dunn [phone]
Name Phone: Office# Mobile#
PO Box 1065 401 East Broad Street
Current Mailing Address Current Street Address
Dunn, NC 28335 Dunn, NC 28334
City State Zip City State Zip
10. Deed Book No.678 Page No. 134 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).
City of Dunn [e-mail]
Company Name E-mail Address
PO Box 1065 401 East Broad Street
Current Mailing Address Current Street Address
Dunn, NC 28335 Dunn, NC 28334
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.
Steve eu h er City Manager
Type o ri Title or Authority
o°JJA-1-1 2P23
igna ure Date
I, 'l 4I,1W kkj'1 ` OIYY,S , a Notary Public of the County of 4-1
NiState of North Carolina, hereby certify that — ,UP(�l I VcChafe,I 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 1
q day of Liar , 20 O3
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al My commission expires I 0 pg
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' Excise Tax Recording Time.Book and Page
Tax Lot Na. ...I Parcel Identifier No.
Verified by County on the day of .. , x9
by ............... .............. . - --._
Mail after recording to (.d f ..7�:£.*ii -.-
Th1Z g instrument was prepared by BcrAen...arbd�Lytch, P. A., P.„Q.,•Bak 3 51.,,••Donny,,N. C. 2$334 _
Brief description for the Index ,
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NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made this 22 day of September , 1.9 . .78..., by and between '
GRANTOR • GRANTEE
=EY B. JOHNSCN and wife, CITY OF DUNK , a North Carolina , .
. FAY S. JOHNSON - municipal corporation
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Enter in appropriate block for each party: name. address, and, it appropriate, character of entity. e.q. corporation or partnership.
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and
shall include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH. that the Grantor. for a valuable consideration paid by the Grantee, the receipt of which is. hereby
acknowledged, has and by these presents does grant, bargain, sell and convey unto the Grantee in fee simple, all that
certain lot or parcel of land situated in the City of ..;. Dunn ........•., Averasboro =Township, .
Harnett County. North Carolina and more particularly described as follows:
BEGII KING at a concrete monument, the northwestern corner of the "Town
of Dunn" lands, Deed Book 415, Page 357, the southeastern corner of the
Alsey B. Johnson lands, Deed Book 331, Page 118, and the southwestern corner
' of J. W. Edwards lands, Deed 631, Pages ,287-288, Harnett County Registry.
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' Frau the BEGINNaG POINT runs thence South 00° 51' 00" East with the
City of Dunn 495.72 feet to a point; runs thence South 25° 12' 00" West •
76.67 feet to a point; runs thence South 51° 00' 40" West 41.73 feet to a
paint; thence North 73° 35' 30" West 94.63 feet to a point; thence North
84° 59' 10" West 79.38 feet to a point; thence North 33° 32' 30" West with
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the City of Dunn existing westside waste water treatment plant 412.26 feet
to a point, a corner; thence South 56° 27' 30" West a portion of the distance
with the westside waste water treatment plant 297.97 feet to a point, a corner;
thence North, 34° 19' 30" West 172.64 feet to a point, a corner; runs thence
North 55° 17' 23" East 775.59 feet to a point, a corner; thence South 40°
27' 00" East 251.99 feet to the concrete monument, being 7.533 acres accord-
ing
to plat prepared by Davis--Martin and Associates, Inc., dated March, 1977,
entitled "Property of Dunn, Job Number E 451-8", further referred to as
"Proposed P.T.c perty Acquisition for Westside Plant Expansion".
N.C.liar Assoc. Form No. 3 CO tl76, Revised 1977. ..
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The property hereinabove described was acquired by Grantor by instrument recorded in k,.•332 ...p a.ge..118, ........
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Harnett Cc anty Registry. • ,,,
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A map showing the above described property is recorded in Plat Book I page 56 w I .
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to
the Grantee in fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has the right to convey •
the same in fee simple, that title is marketable and free and clear of all encumbrances, and that Grantor will warrant and ,
defend the title against the lawful claims of all persons whomsoever except for the exceptions hereinafter stated.
Title to the property hereinabove described is subject to the following exceptions: •
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L1 WITNESS WHEREOF. the Grantor has hereunto set his hand and sealer if corporate, has th s Instrument to be signed in its
corporate runs• by its duly authorized officers and its seal to be hereunto affix authority of its 8 r o 'Directors, the dal► sad year fuss
above written.
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(Corporate Name) sey a -' A- - w .
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FITTEST: C.;
•~. - — ` •Secretary(Corporate Seal) rrx
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Harnett
sx tL-$?AMPJ: NORTH CAROLINA, ...County.
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.:: •I''� ••1,a! I, a Notary Public of the County and State aforesaid, certify that
Alsey B. Johnson & wife, Fair S. Johnson Grantor,
.0: .spersonally appeared before me this day and acknowledged the execution of the foregoing Instrument.Witness ray
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- (I n i `G p hand and official stamp or seal,this '� day of ,._-� _ - , 19 7• -.
_�:� _G My commission expires:_� - 7 _ ,C�.!tt. . Notary Puudlic
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sEAk.STAair NORTH CAROLINA, County.
• I, a Notary Public of the County and State aforesaid, certify that ........--_r------o
,• � • • at personally came before me this day and acknowledged that _--- he is Secretary of
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at • a North Carolina corporation, and that by authority duly
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fit given and as the act of the corporation, the foregoing instrument was signed in its name by its
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2 president, sealed with its corporate seal and attested by as its ___________N_..______—__.. Secretary 1
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Witness my hand and official stamp or seal, this -- -_day of _____. 11--.�.•r... 1
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MY commission expires: Notary Public 1
The foregoing Certificates) of - _ J _ - iiii -Ii____iiii
• is/are certified to be correct. This instrument and this certificate are duly registered at tine date and time and is the Sock and page shown on the
first pz.ge root.
...MI"-- . 9QP .LA2Jarr+rr_-REGISTER OF DEEDS FOR.. COV NTT
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N.C.Bar Assoc_Ferns Na.3 C 1176,Revised 1177. • •
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