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HomeMy WebLinkAboutNCC233360_FRO Submitted_20231109 Check if this project is ARPA-funded ❑ 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 NCG01 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 Johnson Ridge—Lots 1, 3, 5, 7, 9, 11, 13, 15, 21, 23, 25, 27, 29, 31 & 33 "If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Johnston City or Township Elevation Township Highway/Street Johnson Ridge Way Latitude(,,,°,deq,e, )N 35.4487° Longitude«°°,,,,,,deg,°es;W-78.4655° 3. Approximate date land-disturbing activity will commence: October 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.16 Acres 6. Amount of fee enclosed: $ Already Paid . 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 No 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Hannah McGrath E-mail Address permitting a(�,benstoutconstruction.com Phone: Office# 910-779-0019 Mobile# 9. Landowner(s) of Record (attach accompanied page to list additional owners): Old School Road, LLC 919-934-6109 N/A Name Telephone Fax Number 401 North Second Street Same Current Mailing Address Current Street Address Smithfield NC 27577 Same City State Zip City State Zip Lots 1,13,15, 21 & 33 Lots 1,13,15, 21 & 33 10. Deed Book No. 6375 Page No. 573 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). Benjamin Stout Real Estate Services, Inc. brian(W,benstoutconstruction.com Company Name E-mail Address 1786 Metromedical Drive Same Current Mailing Address Current Street Address Fayetteville NC 28304 Same City State Zip City State Zip Phone: Office# 910-779-0019 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: Benjamin Stout benbenstoutconstructjon.com Name of Registered Agent E-mail Address 1786 Metromedical Drive Same Current Mailing Address Current Street Address Fayetteville NC 28304 Same City State Zip City State Zip Phone: Office# 910-779-0019 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 D. Walker President Type or print name Title or Authority C`-Ce.4.- lick.)?.e., ,o/z 4 l.23 Signature Date t'[m 1 1, J � > , a Notary Public of the County ofi CM -0C\ State of North Carolina, hereby certify that (VA-C\ • WEAV-C 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 )� day of IJCA'O , 20 Q.3 +(matt! ItIAADA .Q .;Ss�o�F�;•..Bd,: Notary :17 Cr �0SARY = My commission expires 7 lapg` PUB,-‘"• :_ • 06�ua 1'2 . ',,,'a u u f a,,,,,,,,, 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: Benjamin Stout Real Estate Services, Inc. 910-779-0019 Name Phone: Office# Mobile# 1786 Metromedical Drive Same Current Mailing Address Current Street Address Fayetteville NC 28304 Same City State Zip City State Zip Lots 29 & 31 Lots 29 & 31 Deed Book No. 6544 Page No. 916 Provide a copy of the most current deed. Landowner 3 of Record: Benjamin Stout Real Estate Services, Inc. 910-779-0019 Name Phone: Office # Mobile# 1786 Metromedical Drive Same Current Mailing Address Current Street Address Fayetteville NC 28304 Same City State Zip City State Zip Lots 7,23,25 & 27 Lots 7,23,25 L, . Deed Book No. 6544 Page No. 967 Provide a copy of the most current deed. Landowner 4 of Record: Benjamin Stout Real Estate Services, Inc. 910-779-0019 _ Name Phone: Office# Mobile# 1786 Metromedical Drive Same Current Mailing Address Current Street Address Fayetteville NC 28304 Same _ City State Zip City State Zip Lots 3,5,9& 11 Lots 3,5,9 & 11 Deed Book No. 6547 Page No. 867 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.