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HomeMy WebLinkAboutNCC240408_FRO Submitted_20240220 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Cornbread Valley Mitigation Site 2. Location of land-disturbing activity: County Macon City or Township Franklin 1765 N Jones Creek Road 35.101330 N -83.455015 W Highway/Street Latitude(decimal degrees) Long itude(decimal degrees) 3. Approximate date land-disturbing activity will commence: Stream and Wetland Mitigation 4. Purpose of development (residential, commercial, industrial, institutional, etc.): 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 26 ac 6. Amount of fee enclosed: $2600 . 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 Jake McLean E-mail Addressjmclean@wildlandseng.com Phone: Office# (828)-774-5547 Mobile# (828)-545-3865 9. Landowner(s)of Record (attach accompanied page to list additional owners): See attached Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip 10. Deed Book No. Page No. 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). Wildlands Engineering, Inc. jmclean@wildlandseng.com Company Name E-mail Address 167-B Haywood Road 167-B Haywood Road Current Mailing Address Current Street Address Asheville, NC 28806 Asheville, NC 28806 City State Zip City State Zip Phone: Office# (828)-545-3865 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: N/A 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: Shawn D.Wilkerson, Registered Agent/Manager swilkerson@wildlandseng.com Name of Registered Agent E-mail Address 1430 South Mint Street, Suite 103 1430 South Mint Street, Suite 103 Current Mailing Address Current Street Address Charlotte, NC 28203 Charlotte, NC 28203 City State Zip City State Zip Phone: Office# (704) 332-7754 Mobile# (704) 332-3306 (fax) Name of Individual to Contact(if Registered Agent is a company) 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. Shawn D. Wilkerson President Type or print name Title or Authority 1/19/2023 Signat a Date I, 4jA/lo / k;nil ety. , a Notary Public of the County of `✓)e,G4/0 , it/ !k State of North Carolina, hereby certify that `jhg`Vn ahtoappeared 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 Ili day of JarNt, k , 20 2 fliJvy �= Notary CHARLO�� P. Kie.NEY NOTARY PUBLIC My commission expires // / $ 747'2 6 Mecklenburg County; North Camllna.,