NCC242651_FRO Submitted_20240829

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 Repair Various SJAFB Streambank and Outfall Protection
2. Location of land-disturbing activity: County Wayne City or Township Goldsboro
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:9/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Military
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13.5 Acres
6. Amount of fee enclosed: $ 1,400 . 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 0 No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Troy Martinson, P.E. E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Brian Joyner, P.E. [phone] [phone]
Name Phone: Office# Mobile#
1095 Peterson Ave. 1095 Peterson Ave.
Current Mailing Address Current Street Address
Seymour Johnson AFB, NC, 27531 Seymour Johnson AFB, NC, 27531
City State Zip City State Zip
10. Deed Book No.394 Page No.509 Provide a copy of the most current deed.
*2.
Work Area 1 - Burge St. Latitude 35.3324646 Longitude -77.9699275
Work Area 2 - Jabara Ave. Latitude 35.360239 Longitude -77.9630511
Work Area 3 - Dargue Ave. Latitude 35.356106 Longitude -77.9543567

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).
United States Air Force [e-mail]
Company Name E-mail Address
1095 Peterson Ave. 1095 Peterson Ave.
Current Mailing Address Current Street Address
Seymour Johnson AFB, NC, 27531 Seymour Johnson AFB, NC, 27531
City State Zip City State Zip
Phone: Office# [phone] Mobile# [phone]
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.
Brian W. Joyne Deputy Base Civil Engineer
Typ%e print a Title or Authority
6/28/23
4.4.4
Signature y/ Date
I, �i1 e1`ri b+h Lal , a Notary Public of the County of Wart
State of North Carolina, hereby certify that be Ian W 3° 1 nce 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 21 day of —kne , 20 23
4404)3d-h. gne-146
\`\ ,(<'��Zp BE Ty 14//=. Nota Z'J
o
z NototY Public = My commission expires.4jU41.51 24) 2023
C9 Wayne CouriiY �J
O

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#

EROSION and SEDIMENTATION CONTROL PLAN PRELIMINARY REVIEW CHECKLIST
The following items shall be incorporated with respect to specific site conditions,in an erosion&sedimentation control plan:
NPDES Construction Stormwater General Permit NCG010000
Designation on the plans where the 7 or 14 day ground stabilization requirements apply per Part II.E.1 of the permit.
I .
Design of basins with one acre or more of drainage area for surface withdrawal as per Part II.B.8 of the permit.
LOCATION INFORMATION Q Name and classification of receiving water course or name of
municipal operator (only where stormwater discharges are to
O Project location&labeled vicinity map(roads,streets,landmarks) occur)
O North arrow and scale
(O Identify River Basin. STORMWATER CALCULATIONS
O Provide a copy of site located on applicable USGS quadrangle and
NRCS Soils maps if it is in a River Basin with Riparian Buffer r] Pre-construction runoff calculations for each outlet from the site(at
requirements. peak discharge points). Be sure to provide all supporting data for
the computation methods used (rainfall data for required storm
GENERAL SITE FEATURES(Plan elements) events, time of concentration/storm duration, and runoff
coefficients).
NM Property lines&ownership ID for adjoining properties Q Design calculations for peak discharges of runoff (including the
0 Existing contours(topographic lines) construction phase&the final runoff coefficients for the site)
0 Proposed contours I-7 Design calcs for culverts and storm sewers(include HW,TW and
0 Limits of disturbed area (provide acreage total, delineate limits, outlet velocities)
and label). Be sure to include all access to measures,lots that will r—I Discharge and velocity calculations for open channel and ditch
be disturbed,and utilities that may extend offsite. flows(easement&rights-of-way)
Planned and existing building locations and elevations 1--1 Design calcs for cross sections and method of stabilization for
0 Planned & existing road locations & elevations, including existing and planned channels(include temporary linings). Include
temporary access roads appropriate permissible velocity and/or shear stress data.
Lot and/or building numbers En Design calcs and construction details for energy dissipaters below
0 Hydrogeologic features: rock outcrops, seeps, springs, wetland culvert and storm sewer outlets (include stone/material specs &
and their limits, streams, lakes, ponds, dams, etc. (include all apron dimensions).Avoid discharges on fill slopes.
required local or state buffer zones and any DWQ Riparian Buffer Q Design calcs and dimension of sediment basins (note current
determinations) surface area and dewatering standards as well as diversion of
Q Easements and drainageways, particularly required for offsite runoff to the basins). Be sure that all surface drains, including
affected areas. Include copies of any recorded easements and/or ditches and berms,will have positive drainage to the basins.
agreements with adjoining property owners.
Profiles of streets,utilities,ditch lines,etc. VEGETATIVE STABILIZATION
I Stockpiled topsoil or subsoil locations
If the same person conducts the land-disturbing activity & any 0 Area&acreage to be stabilized with vegetation
related borrow or waste activity, the related borrow or waste 0 Method of soil preparation
activity shall constitute part of the land-disturbing activity unless 0 Seed type&rates(temporary&permanent)
the borrow or waste activity is regulated under the Mining Act of 0 Fertilizer type and rates
1971, or is a landfill regulated by the Division of Waste 0 Mulch type and rates(include mulch anchoring methods)
Management. If the land-disturbing activity and any related
borrow or waste activity are not conducted by the same person, NOTE: Plan should include provisions for groundcover in accordance with
they shall be considered separate land-disturbing activities and NPDES Construction Stormwater General Permit NCG010000.
must be permitted either through the Sedimentation Pollution
Control Act as a one-use borrow site or through the Mining Act. FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
O Location and details associated with any onsite stone crushing or
other processing of material excavated. If the affected area ri Completed,signed&notarized FR/O Form
associated with excavation, processing, stockpiles and transport 1 1 Accurate application fee payable to NCDEQ ($100.00 per
of such materials will comprise 1 or more acres,and materials will acre rounded up the next acre with no ceiling amount)
be leaving the development tract,a mining permit will be required. Certificate of assumed name,if the owner is a partnership
I• Required Army Corps 404 permit and Water Quality 401 Name of Registered Agent(if applicable)
certification(e.g.stream disturbances over 150 linear feet) Copy of the most current Deed for the site. Please make sure the
"Permit applications under review deed(s) and ownership information are consistent between the
EROSION&SEDIMENT CONTROL MEASURES(on plan) plan sheets,local records and this form.
r7 Provide latitude & longitude (in decimal degrees) at the project
O Legend (provide appropriate symbols for all measures and entrance.
reference them to the construction details) I-1 Two hard-copies of the plans (some regional offices require
( I ( Location of temporary measures additional plans or multiple sizes; please contact the regional
O Location of permanent measures coordinator prior to such submittal.)
I Construction drawings and details for temporary and permanent
measures. Show measures to scale on plan and include NOTE: For the Express Permitting Option, inquire at the local Regional
proposed contours where necessary. Ensure design storage Office for availability. Express Reviews are performed by
requirements are maintained through all phases of construction. appointment only.
0 Maintenance requirements for measures NARRATIVE AND CONSTRUCTION SEQUENCE
0 Contact person responsible for maintenance
rI Narrative describing the nature & purpose of the construction
SITE DRAINAGE FEATURES activity.
H Pre-construction conference,if requested.
ET Existing and planned drainage patterns(include off-site areas that Construction sequence related to erosion and sediment control
drain through project and address temporary and permanent (including installation of critical measures prior to the initiation of
conveyance of stormwater over graded slopes) the land-disturbing activity&removal of measures after areas they
Q Method used to determine acreage of land being disturbed and serve are permanently stabilized). Address all phases of
drainage areas to all proposed measures(e.g.delineation map) construction and necessary practices associated with temporary
0 Size,pipe material and location of culverts and sewers stream bypasses and/or crossings.
0 Soil information: type,special characteristics 0 Bid specifications related only to erosion control
0 Soil information below culvert storm outlets rev. 1-18-22

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USGS Topographic Map
Drawing 1 Seymour Johnson AFB
USGS Topographic Map , , ,
4 , ^ Streambank and Outfall Repair
Southeast Goldsboro, NC Quadrangle I
Goldsboro, Wayne County, NC
Scale: 1" 2,000'
PILO/ INVIRONMINTAL 11.1C
Pilot Project 6188

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Seymour Johnson AFB
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of Wayne County, NC ... �
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, PILO, INV RONMINTAL iNC Pilot Project 6188

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