NCC215427_FRO Submitted_20211001

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 Environment and Natural Resources. (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.
1. Project Name Union County — Worwood Acres Water Main Replacements
2. Location of land -disturbing activity: Union County City or Township: Indian Trail
3. Highway/Street: Potter Road, Middleton Avenue, Robinson Avenue, Caroline Drive, Davidson Drive
Latitude: 35.065047 Longitude:-80.698330
3. Approximate date land -disturbing activity will commence: June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Water Mains
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.3 acres
6. Amount of fee enclosed: $ 325.00 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Shutak, P.E. E-mail john.shutak(a)-unioncountync.gov
A
Telephone [phone] Cell # 704-993-0365
Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Rights -of -Way _
Name Telephone
Current Mailing Address
City State
10. Deed Book
Part B.
Current Street Address
Zip City
Page No.
State
Fax Number
Zip
Provide a copy of the most current deed.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Union County
Name
500 N. Main Street, Suite 600
Current Mailing Address
iohn.shutak(ab-unioncountync.gov
E-mail Address
500 N. Main Street, Suite 600
Current Street Address
Monroe, North Carolina 28112 Monroe, North Carolina 28112
City State Zip City State Zip
Telephone [phone] Fax Number 704-296-4232

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:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
(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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
John Shutak. P.E
Type or print name
Signature
---------------------------------------------------------------
Engineering Division Director
Title or Authority
Date
I, Z : '044t 1�,�j� �,� , a Notary Public of the County of tZA�' , o
State of North Carolina, hereby certify that --� E c , - k +, - /A 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,
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