HomeMy WebLinkAboutNCC215325_FRO Submitted_20210929FINANCIAL 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Suits Homes Erosion Control Plan
1. Project Name
tj
3.
4.
5.
6.
VA
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a
Location of land -disturbing activity: CountyChatham City or Township Siler City
Highway/Street 2699 Alston Bridges Rd. Latitude35.7139 -_ Longitude-79.4233
Approximate date land -disturbing activity will commence: September 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.3 acres
Amount of fee enclosed: $260 The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kent Suits E-mail Addresskents@suitshomes.com
Telephone (919)-663-2406 cell # (336)-669-3724 Fax # N/A
Landowner(s) of Record (attach accompanied page to list additional owners).
Donovan Campbell (919)-478-3473
Name Telephone
5127 Ponderosa Rd N/A
Current Mailing Address
Sanford NC
City State
10. Deed Book No.2051
27332
Current Street Address
N/A
Zip City
Page No.400
State
N/A
Fax Number
Zip
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Donovan Campbell askwiggy@aol.com
Name E-mail Address
5127 Ponderosa Rd n/a
Current Mailing Address Current Street Address
Sanford NC 27332 n/a
City State
Telephone (919)-478-3473
Zip City State Zip
Fax Number n/a
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
n/a n/a
Name E-mail Address
n/a n/a
Current Mailing Address
n/a
City
Telephone n/a
Current Street Address
n/a
State Zip City State Zip
Fax Number n/a
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
n/a n/a
Name of Registered Agent
n/a
Current Mailing Address
n/a
City
Telephone n/a
E-mail Address
n/a
Current Street Address
n/a
State Zip City State Zip
Fax Number n/a
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Donovan Campbell
Type or print name
Signature
-----------------------
Property Owner
Title or Authority
5P/iwl- /, . _
Date
f�(Iit ���' � a Notary Public of the County of
State of North Carolina, hereby certify that DOh,�,V:.,-) Ca��-JA appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this clay of YL� sA 20 w
RINARD KENT SUITS
Notary Public, North Carolina
Notary
5e
I Chatham County
My Commission Expires
_ __ _ _
My commission expires ..a,52c:�