SW6061101_COMPLIANCE_20070716

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW
DOC TYPE
❑ CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
COMPLIANCE EVALUATION INSPECTION
DOC DATE
YYYYMMDD
B

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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 - d
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: M3-00014-6P, Construct POV Parking Lot at Rowe Training Facility
2. Location of land -disturbing activity: County Richmond City or Township Camp MacKall
Highway/Street Special Forces Way Latitude 35.04820 Longitude-79.48951
3. Approximate date land -disturbing activity will commence: 11 Oct 2007
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Military
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.55 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 XXX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Craig Lantz E-mail Address jennings.c.lantzpus.army.mil
Telephone [phone], ext. 226 Cell # NIA Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
United States of America N/A N/A
Name Telephone Fax Number
See attached address sheet Same
Current Mailing Address Current Street Address
Fort Bragg
City
10. Deed Book No. N/A
Part B.
NC 28310 Same
State Zip City
State
Page No. N/A Provide a copy of the most current deed.
Zip
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):
Department of the Armv NIA
Name E-mail Address
Sheet attached address sheet Same
Current Mailing Address Current Street Address
Fort Bragg NC 28310 Same
City State Zip City State Zip
Telephone N/A 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:
NIA
Name
NIA
Current Mailing Address
N/A r"
City State Zip
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
City
Fax Number N/A
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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
NIA
E-mail Address
N/A
Current Street Address
N/A
City
Fax Number N/A
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.
Type or f rin/hame
Directorate of Public Works, Fort Bragg
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that 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
Notary
Seal
My commission expires

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