NCC231178_FRO Submitted_20230515

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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. Protect Name HUntersville Athletic Park
2. Location of land-disturbing activity: County Mecklenburg City or Township Huntersville
Highway/Street 11836 Verhoeff Dr Latitude(dec!meldegrees)35.39 Longitude(dedme de0rees)'g0.84
3. Approximate date land-disturbing activity will commence:Jan 2023
4. Purpose of development(residential,commercial, industrial,institutional,etc.): Recreational/Park
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):3.75 Acres
6. Amount of fee enclosed:$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 0 Enclosed Ri No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Jaycocks E-mail Address [e-mail]
Phone: Office# 704-766-2228 Mobile#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Mecklenburg County 7043367600
Name Phone: Office# • Mobile#
600 E 4th St Floor 11
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip City State Zip
10. Deed Book No.898 Page No. 241 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(he owner(s)maybe listed as the financially responsible party(ies).
Town of Huntersville Parks and Recreation [e-mail]
Company Name E-mail Address
P.O. Box 2879 105 Gilead Rd, 3rd Floor
Current Mailing Address Current Street Address
Huntersville NC 20078 Huntersville NC 28078
City State Zip City State Zip
Phone: Office# 704-766-2228 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.
MI i�a.el jck?co� IoirkS a4 °pCf��, �/1 6,reAor
Type or print name Title or Authority
Signatur Date
I, 1 l�►��t E Pr i t-i-s , a Notary Public of the County of M (;CK LGNSI'G
State of North Carolina, hereby certify that I C H 4k E L ANCDCKS 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 22 day of NA A2C , 20 23
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TRAMAINE MILLS �SfQMGr'—
Notary Public, North Carolina Notary
Mecklenburg County
My Con rruission Expires
April 25, 2026 My commission expires Ape'i L '2�r 202L-

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:
Mecklenburg County 7043367600
Name Phone: Office# Mobile#
600 E 4th St Floor 11
Current Mailing Address Current Street Address
Charlotte NC 28202
City State Zip City State
Zip
Deed Book No. 675 Page No. 11 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 cop
y 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.

Re: Huntersville Athletic Park
Dear N.C. Department of Environmental Quality,
This letter is in reference to the Erosion and Sedimentation Control Plan
application submitted by the Town of Huntersville for Huntersville
Athletic Park located at 11836 Verhoeff Drive in Huntersville.
As the landowner of this park property, Mecklenburg County gives
consent to the Town of Huntersville to submit this application and to
conduct the anticipated land disturbing activity for the Huntersville
Athletic Park Turf Project.
If you need additional information, please let us know.
Signature Date