NCC241219_FRO Submitted_20240507

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 Black River WWTP Effluent Conveyance Improvements
*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).
SRP-W-ARP-0288
2. Location of land-disturbing activity: County Harnett City or Township Dunn
Highway/Street SR 1776, Hwy 82 Latitude�aa����a��ees)35.2973 Longitude�aa��al degrees -78.6366
3. Approximate date land-disturbing activity will commence: 5/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Sewer Force Main
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 14.7
6. Amount of fee enclosed: $1500 . 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 D Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Steven Neuschafer, City Manager E-mail Address [e-mail]
Phone: Office# 910-230-3500 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Dunn 910-230-3500
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.449 Page No. 136 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 Steet
Current Mailing Address Current Street Address
Dunn NC 28335 Dunn NC 28334
City State Zip City State Zip
Phone: Office# 910-230-3500 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 Asi 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.
Steven e schafer City Manager
Type or in a e Title or Authority
OS Pr Zo Zt3
ignature Date
I, NNW'/►( ' 1, l'A j , a Notary Public of the County of e.,0
State of North Carolina, hereby certify that J"TL t`'t')5CWk$€( 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 ()� 0 day of 'OQ.e A\A. , 20 2.3
„0 GR(-)///, eVer
�' T RY_'•:�= Notary
. •
•
My commission expires UI 40 202([Y�\

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:
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
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.

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 #

NORTH CAROLINA,.. ,.r liar nett c . . .. --- r County.
WHEREAS, Dunn
..
Production Credit Association, a corporation (hereinaftercalled Lender as agreed to make aances to
Nitta dt
a MoNe i�
(hereinafter called Borrower, whether one or more), in an aggregato amount no aaitai d...fi�i"►i�._ , ...t!! !!! ,�
Dollars ($ 4OO OO.--..), for the purpose of enabling Borrower to culti-
vate the lands hereinafter described, evidenced by an installment note of even date herewith, providing for interest rate, amounts and dates of
advances, maturity date(s), and other terms:
THEREFORE, in consideration of said advances and One Dollar ($1.00), paid to Borrower by Lender, receipt acknowledged, and for bet-
tor sectlripg said advances, and any additional advances (not exceeding an equivalent amount) that may subsequently be made to Borrower
by Lender, and all renewals and extensions thereof, and all other indebtedness now due or to become clue or hereafter to be contracted,
with interest and costs, undersigned, in accordance with Section 2480 of the Consolidated statutes of North Carolina, hereby grants an
agricultural lien on, and conveys unto Lender, its successors and assigns, all crops made...within one (1) year from date hereof, on the fol-
lowing described 1and:i, situate in WPM ,
TowashiAIM*tt County, North Carolina, to wit:
Q in ainix g 22 Rave .
0 more or less .
owned and operated by Bomar,
ad jol ins the lands Anna M*- . =.. ; w sale McLean and Ma Shea* •
J• .'f * , . ,, to.. ir'`)
. .1.CO
1.9-
FOR THE CONSIDERATION AFORESAID, and to f �¢ secusi the i .a•.4. Hess. undersigned hereby grants, bargains, sells and conveys
1 w ing descunto ribed chattels,its rs and all tobacco sticks now owned and the above he : - bOsr = .■`.,-i and all fertilizer and other live agricultu al supplies thereof,
sed with
the advances hereby secured, wheresoever the same may be locate. .
l Breeam Mile, age 5 yr s . wt. 1200#.
B Black and white spotted shoats, age 9 mos. wt. 100# ea. .
•
Islas wagon Piedmont .
Ieweorn pester
go
1-8we ep plow -
And all other f'- _ ', : , ; -' . a awned by Applicant.
C.;-'r P
i
- . .. r. -
�. .. .. .
1 'i•
TO HAVE AND TO HOLD said property unto Lender • ccesss`a • r= , . s forever; PROVIDED, that after Borrower shall pay, when
due, all Indebtedness hereinbefore mentioned, then this i •i�+" •a 1 \' - d.
FOR THE CONSIDERATION AFORESAID, undersigns. �tf j, ,,it • • .grees to and with Lender: That all advances hereunder shall be se-
cured hereby, whether made before or after the assignment of t- . ent, and whether made by Lender or an assignee hereof. All notes
secured hereby and assigned to, and all advances made by, an assignee hereof, shall have priority over other notes secured hereby and advances
hereunder. That application of Borrower, as approved by Lender and the notes executed by Borrower to Lender, and all other instruments exe-
cuted in connection therewith, are made a part hereof, as if set forth in extenso herein, and with this instrument constitute the contract be-
tween undersigned and Lender; and in the event of any misrepresentation or default in said contract, or should the security hereof be dimin-
ished or be in danger of loss, removal or destruction, Lender, its successors and assigns. may, at its option, without notice, do any' or all of the
following: Declare all indebtedness hereinbefore mentioned immediately due and payable and exercise any rights, powers, or privileges and pur-
sue any remedies provided in said contract and any others provided by law; enter without suit or process upon the premises where any of the
crops, livestock or other personal property may be located, take possession thereof and after advertising same for five (5) days at the court-
house door and three (3) other public places in the county(les) in which said property is located, sell any' or all of same at public auction to
the highest bidder for cash, at the time(s) and place(s) to be designated in the notices of sale, at which sale Lender may become the pur-
chaser, and after paying costs incurred in seizing, transporting, caring for, preparing, handling, advertising and selling said property, apply
the proceeds of said sale to the hereinbefore mentioned indebtedness, interest, charges, costs and any other expenses provided for in said con-
tract, paying any surplus to undersigned.
Undersigned hereby warrants title to said pros against all persons whom ever. h
ai
EXECUTED, SEALED AND DELIVERED h ss day of , 19417
-- .fie tl tt,a L--M l�1„ (L. S.)
Signed, Sealed and Delivered in the presence of: i . .. (L. S.)
Lik...esias.n. - (I.. s.)
(L. S.)
FOR EXECUTION BY LANDLORD
The undersigned, being the owner of the land described in the within instrument, in consideration of the advances to be made, as therein
provided, do hereby waive, release, postpone and assign unto Lender, its successors and assigns, all liens, for rent, supplies and advances. in
favor of the indebtedness secured by the within instrument, to the end that the lien of the within instrument shall he prior to the landlord's
liens, for rent, supplies and advances until the indebtedness secured by the within instrument has been paid in full, including interest, and costs
of collection, as provided for in the within instrument and/or note(s) secured thereby.
EXECUTED, SEALED AND DELIVERED this day of , 19.............
Witness: (L.S.)
(L. S.)
(1) PROOF BY WITNESS
Harnett .
NORTH CAROLINA, County.
The execution of the foregoing instrument and landlord waiver, was this day proven before me by oath and examination of
iw+ 0 i 0.1.1' , the subscribing witness(es)
thereto. Let the same with this certificate be registered.
Witness my hand (and official seal), this 5th day of . March 47, 19
My Commission Expires -Do P. Ray, 3'r•
Ray,
Witty Aso. j (Official Title)
C. L. & C. If., N. C. Rev. 7-1-46. • PCA-401

(2) ACKNOWLEDGMENT BY GRANTORS
NORTH CAROLINA, County.
(Name of Officer)
a....... ..........._... do hereby certify that
(Title)
personally
appeared before me this day and acknowledged the due execution of the foregoing instrument and landlord waiver. Let the same with this
eertificate be registered,
Witness my hand (and official seal), this day of ......._................. 19......
My Commission Expires;
(3) CERTIFICATE FOR CORPORATIONS
NORTH CAROLINA, County.
This is to certify that on the day of , 19 , before me, personally
came _. . with whom I am per-
sonally acquainted, who being by me duly sworn, says that is the
President and .. .._. ....... is the Secretary of the
, the corporation described in and which executed the foregoing instru-
ment; that he knows the common seal of said corporation; that the seal affixed to the foregoing instrument is said common seal, and the name
of the corporation was subscribed thereto by said President, and that said President and
Secretary subscribed their names thereto, and said common seal was affixed, all by order of the Board of Directors of said corporation, and
that the said instrument is the act and deed of the said corporation. Let the instrument with the certificate be registered.
Witness my hand (and official seal) this................_...._ day of .. .._..___............._..._....._....____......_.___, 19
My Commission Expires:
..»._._._....._..._._..................•--_..........._..»._ ...���..............._..�..._......... _. (Official Title) ...........».�
(4) CERTIFICATE FOR REGISTRATION
NORTH CAROLINA, County.
The foregoing certificates) of
(Name of Officer)
a , is adjudged to be correct. Let the instrument and
(Title)
the certificate(s) be registered. Dated , 19 (Clerk of the Superior Court)
NORTH CAROLINA, na rnet t
ounty.
I hereby certify that the within crop liens, chattel mortgage and landlord's waiver were filed and/or lodged for record in my office at
_. M. o'clock on the 7 day of Mg.r e-h , 19 4 7 d entered on the proper
indexes and duly recorded in Chattel Mortgage Book 449 , at page 136
Inez Barrington,
(Register of Deeds)
WAIVER OF SHARE-CROPPER AND/OR LABORERS' LIEN
(Not to be recorded)
In consideration of the advances mentioned in the within instrument the undersigned hereby waive(s) and postpone(s) in favor of lend-
er, its successors and assigns, any and all liens, claims and encumbrances to and upon the crops and other personal property described
therein which may now or hereafter exist in favor of undersigned.
This the day of........ , 19
WrTI1nss: (L. S.)
....(L. S.)
». (...---. (L. S.)
... (L. S.)
(L. S.)
(L. S.)
•

NORTH CAROLIN A,
HARNETT COUNTY.
THIS DFFD, Made this 17th day of April , 1964 by ALSEY JOHNSON
and wife , FAY S . JOHNSON , of Harnett County, North Carolina,
parties of the first part , to the TOWN OF DUNN , a municipal
corporation organized and existing under the laws of the State
of North Carolina, party of the second part ;
W I T N E S S E T H : is
That said parties of the first part , in consideration of
One Hundred Dollars and ether valuable considerations . to them
paid by said party of the second part , the receipt of which is
hereby acknowledged , have bargained and sold snd by the s,e presents
do b argain, sell and convey to said party of the second part, its
successors and assigns , that certain tract or parcel of land lying and
being in Harnett County, North Carolina, more particularly described
as follows :
BEGINNING at a stake located in the southwest corner of the
2-acre tract owned by the Town of Dunn on which is located the sewage
treatment plant , which stake is also located on the west bank of
P
Black River, and runs thence North 61 deg . 30 min. East with the
line of the Town of Dunn 2-acre tract 4.14). 86 feet to a stake ;
thence South 28 deg. 30 min . East 4.15,22 feet to a stake ; thence
South 61 deg . 30 min. West 325 feet to a stake on the west bank of
Black River ; thence up the west bank of Black River as it meanders
in a northerly direction to the b eginning, containing 3 . 8 acres
more or less and being part of the land described in deed recorded
in Book 331, Page I16, Office of Register of Deeds , Harnett County.
TO HAVE AND TO HOLD , the aforesaid tract or parcel of land
with all privileges and appurtenances thereto belonging to said
party of the second part , its successors and assigns , to its only use
and behoof forever .
And said parties of the first part , for themselves , their heirs ,
executors and administrators , covenant with said party of the
second part , its successors and assigns , that they are seized of
said premises in fee and have right to convey in fee simple ; that,
the same are free and clear of all encumbrances and that they do hereby
warrant and will forever defend the said title to the same against
the claims of all persons whomsoever .
,
- • '.14(. 46e)
4490136 !4T: 1.11'
.a D'Vrr.. ...., . -ig'cr ii;o1Wiet-r3R? ;i�+�, � c i,�. 1: �'T71'F= L' Kp,`i p r% - ., 4`. } ��

4r i ! Ii 1 jl.jril IHl'1'.
I ,
IN TESTIMONY WHEREOF, said parties of the first part have
hereunto set their hands and seals , the day and year first above
written .
i
( SEAL )
Afse ohnson
1'� / • i, �-�._�. �•• . (SEAL )
a • , d"� • son
NORTE CAROLINA,
HARNETT COUNTY
I, ..- 4 , a Notary Public ,
hereby certif that -Alsey Johnson and wife , Fay S . Johneen,
personally appeared before me this day and acknowledged the due
execution of, the foregoing Deed of L'onveyance .
WITNESS my hand and Notarial Seal , this .__..__
'day of April , 1964.
4 L 0
. .- • '''.. . -714. ARY PUBLIC
i t k It r
f. 1 e MI q:sE lon exp res : /—A eiC
r 0 '
t . i.
ri
NIT ARML WA
T wing rtificate of ..1, - 61 j,ap,
i ......._ ovnty is adjudged to be coireet.
Let the instrument with certificate a registered.
/- ' , / l° C. iii
•
Itig..Z)z,i-e ,,,s--- 1,4(-)/
ftied for registration aVir o'clock_. ,:_...M,
- - b ,, 194. and registered in I 8.06111.,...
the Qf fic mid the Re ister of Deeds for Harnett
Count ; in BOA_: ;..3" ,..,,. page ., . .......... ......
. —4----, .19.,(4X
• •---• 'of ... ... .--
w to ster of Deeds, Harne oust et N.
Re Eied ; Vefifiedi".41,u:.,(....ti r..t..:u— 1•.,.n
1 6;