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Home My WebLink AboutNCC242917_FRO Submitted_20240920 Check if this project is ARPA-funded ❑X 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 Southpoint Pump Station and Force Main *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). Southpoint Business Park Pump Station and Force Main 2. Location of land-disturbing activity: County Davie City or Township Mocksville Highway/Street Enterprise Way(SR 1361)&others Latitude(decimal degrees)35.932273 Longitude(decimal degrees)-80.603327 3. Approximate date land-disturbing activity will commence: October 2024 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3_0 6. Amount of fee enclosed: $ 300 . 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 Kenneth Gamble E-mail Address kgamble@mocksvillenc.gov Phone: Office#336-753-6700 Mobile# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Hollingsworth,G.P. 865-457-3601 Name Phone: Office# Mobile# 2 Centre Plaza 2 Centre Plaza Current Mailing Address Current Street Address Clinton TN 37716 Clinton TN 37716 City State Zip City State Zip 10. Deed Book No. 1050 Page No. 1184 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). Town of Mocksville kgamble@mocksvillenc.gov Company Name E-mail Address 171 South Clement Street 171 South Clement Street Current Mailing Address Current Street Address Mocksville NC 28115 Mocksville NC 28115 City State Zip City State Zip Phone: Office#336-753-6700 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 correcte information should there be any change in the information provided herein. e? �� #44.0%i,,Af, 27 . Type or e Title or Authority -�_ / z Signature Date I; r tit) /(_ jc ' \�_��;t-°= -try , a Notary Public of the County of " r`-,l•- L- v� State of North Carolina, hereby certify that _.1) nr) c, -kb—Le , 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 6 day of ,SCoa4aftd_ , 20 , Li,oHNIH►!,q,,,, Q" ,, • • o mtssioq .* ! . -9 -v,i-c-i--e- s-.i ,g NpTAR y N 1 r N �s ua►.• 1el My commission expires ,,,t.L:�-1� 9 O.: ' j 1v aV 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: Hollingsworth,G.P. 865-457-3601 Name Phone: Office# Mobile# 2 Centre Plaza 2 Centre Plaza Current Mailing Address Current Street Address Clinton TN 37716 Clinton TN 37716 City State Zip City State Zip Deed Book No. 1093 Page No. 1138 Provide a copy of the most current deed. Landowner 3 of Record: Hollingsworth Team Partnership 865-457-3601 Name Phone: Office# Mobile# 2 Centre Plaza 2 Centre Plaza Current Mailing Address Current Street Address Clinton TN 37716 Clinton TN 37716 City State Zip City State Zip Deed Book No. 1043 Page No. 1147 Provide a copy of the most current deed. Landowner 4 of Record: Hollingsworth Investments, IV 865-457-3601 Name Phone: Office# Mobile# 2 Centre Plaza 2 Centre Plaza Current Mailing Address Current Street Address Clinton TN 37716 Clinton TN 37716 City State Zip City State Zip Deed Book No. 846 Page No. 864 Provide a copy of the most current deed. Landowner 5 of Record: Amarr Company 1-800-503-3667 Name Phone: Office# Mobile# 3800 Greenway Circle 275 Enterprise Way Current Mailing Address Current Street Address Lawrence KS 66046 Mocksville NC 27028 City State Zip City State Zip Deed Book No. 675 Page No. 400 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: Josh Bryant Mcclamroch Name Phone: Office# Mobile# 293 Brantley Farm Road 293 Brantley Farm Road Current Mailing Address Current Street Address Mocksville NC 27028 Mocksville NC 27028 City State Zip City State Zip Deed Book No. 409 Page No. 694 Provide a copy of the most current deed. Landowner 7 of Record: Jonathan Russell Angell Name Phone: Office# Mobile# 321 Brantley Farm Road 321 Brantley Farm Road Current Mailing Address Current Street Address Mocksville NC 27028 Mocksville NC 27028 City State Zip City State Zip Deed Book No. 409 Page No. 694 Provide a copy of the most current deed. Landowner 8 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 9 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.