NCC215349_FRO Submitted_20211005

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.
Departmentof Environmental Quality. Submitthe completed form tothe appropriate Regional Office. (Please type or print
and, if the question is not applicable orthee-mail and/orfaxinformation unavailable, place N/A in the blank.)
Part A.
Project Name Yadkin Valley Sewer Authority Stfeam St4'lization/Enhancement Project
Location of land -disturbing activity: CountyYadkin City or Township Jonesville
Highway/Street Latitude 36_2.26488 (Site 1): 36.242988 (Site 2136.241774 (Sitg 3)
Longitude -80,849789 Sit i Site 2 • -80 1 it
3. Approximate date land -disturbing activity will commence: September 2 21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Stream
Stghalization/Enhancement
5. Total acreage disturbed oruncovered (including off -site borrowand waste areas): 2.8 AC
6. Amount of fee enclosed: $_ 195.00 . 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. Emmett Perdue E-mail Address_ eoerduec�D. eorusa.net
Telephone [phone]_ Cell # 919-215-6757_ Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Yadkin Vallev Sewer Authority 336- 5 9819 NIA
Name Telephone Fax Number
500 LIC Hwy 268 W 500 NC Hwy
Current Mailing Address Current Street Address
Elkin NC 28621 Elkin NC 28621
City State Zip City State Zip
10. Deed Book No. 107 (A): 267 (B): 734 (C): 1242 (13): 1072 Q Page No. 144 (A): 602 (BI:
039 C • 604 D 4 E 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 maybe listed as the frnanciallyresponsible party.
Yadkin Valley Sewer Authority
Name
500 NC Hwy 286 W
Current Mailing Address
Elkin f Imo_ 28621
City State Zip
nic I .' hn ton sva.
E-mail Address
500 NC Ha 286 W
Current Street Address
Elkin NC 28621 _
City State Zip

Telephone 1 Fax Number NIA
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone,
Fax Number
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.
i rj0 j _Q T 6%_%Ao r) e u4; ve_. _ i rft�c r
Type or print name Title or Authority
Signature Date
------------------------------ —------- ---------------- ------------- ------- --------- --------------------------- --- ------
a Notary Public of the County of w t I e
t
State of North Carolina, hereby certify that lV i (0 LQ A O1rtint-on _ 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 day of 20
E
Y. HAYES Notary
Y PUBLIC a�D
ty, North Carolina My commission expires

Accompanied Page
Additional Owners
9A. Landowner(s) of Record (attach accompanied page to list additional owners):
Vera Lvndol Haynes 336-835A383 NIA
Name Telephone Fax Number
3509 Shaff ner Rd. 35Q9 Shaffner Rd.
Current Mailing Address Current Street Address
Jonesville T NC 28642 Jonesville NQ 28642
City State Zip City State Zip
10A. Deed Book No. 107 Page No. 144 Provide a copy of the most current deed.
9B. Landowner(s) of Record (attach accompanied page to list additional owners):
Robert and Brenda on
Name
Telephone
NIA
Fax Number
2 Westbrook St 532 Westbrook St.
Current Mailing Address Current Street Address
Jonesville NC 28642 Jonesville NC 28642
City State Zip City State Zip
10B. Deed Book No. 267 Page No. 602 Provide a copy of the most current deed.
9C. Landowner(s) of Record (attach accompanied page to list additional owners):
Elkin Jonesville Shrine Club
Name
PO Box 587
Current Mailing Address
Telephone
Current Street Address
NIA
Fax Number
Elkin NC T 28621 _Jonesville INC ,28642
City State Zip City State Zip
10C. Deed Book No. 734 Page No. 039 Provide a copy of the most current deed.
9D. Landowner(s) of Record (attach accompanied page to list additional owners):
Ricbgrd Wayne Stanley. Jr. & Ricky Jones N/A
Name Telephone Fax Number
10Q Dwayne St 100 Dwayne St
Current Mailing Address Current Street Address
Jonesville NC 28642 Jonesville _ NC 28642
City State Zip City State Zip
10D. Deed Book No. 1242 Page No. 604 Provide a copy of the most current deed.

9E. Landowner(s) of Record (attach accompanied page to list additional owners):
Richard Wayne Stanley. Jr. & Amanda Stanley NIA
Name Telephone Fax Number
1JQ Wilbur Gentry Lane 110 Wilbur Gentry Lane
Current Mailing Address Current Street Address
State Road NC 28676 State Road NC 28676�
City State Zip City State Zip
10E. Deed Book No. 1202 Page No. 221 Provide a copy of the most current deed.
9F. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Jonesville 35-3426 NIA
Name Telephone Fax Number
1503 NC 67 Hwy. 1503 NC 67 Hwy,
Current Mailing Address Current Street Address _
Jonesville _ NC 28642 Jonesville _ NIC 28642
City State Zip City State Zip
10F. Deed Book No. Page No. 274, 324 Provide a copy of the most current deed.