NCC215630_FRO Submitted_20211011

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 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.
3
4
61
Project Name Ellington Subdivision - Camping Creek Rd.
Location of land -disturbing activity: County Franklin
Highway/Street Cam
Creek Rd. Latitude 36.047834
City or Township Harris
Longitude-78.358513
Approximate date land -disturbing activity will commence: Winter 2021
Purpose of development (residential, commercial, industrial, institutional, etc.):
Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.24 Acres
6. Amount of fee enclosed: $ 1040 . 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 Kevin Varnell
E-mail Address kvarnell a,stocksengineering.com
Telephone [phone] Cell # 252-382-0012 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Mark A. Ellington and Susan P. Ellington
Name
1023 Roxboro Road Oxford, NC 27565
Current Mailing Address
919-693-1230
NA
Telephone Fax Number
1023 Roxboro Road Oxford, NC 27565
Current Street Address
Oxford, NC
27565
Oxford,
NC 27565
City State
Zip
City
State Zip
10. Deed Book No. 2265
Page No.
1156-1163
Provide a copy of the most current deed.
Part B.
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.
Mark Ellington [e-mail]
Name E-mail Address
1023 Roxboro Road Oxford, NC 27565 1023 Roxboro Road Oxford, NC 27565
Current Mailing Address Current Street Address
Oxford, NC 27565 Oxford, NC 27565
City State Zip City State Zip

Telephone NA
Fax NumberNA
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
Telephone
E-mail Address
Current Street Address
Zip 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.
k� r►c�b n
Type or print name
At/e
Signature
bw►%Ly'
Title or Authority
7-41- ZI
Date
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I, 0(_ C� E^�hien . \Ml(wt.tt , a Notary Public of the County of (7n►��� ��-
State of North Carolina, hereby certify that (Aao IC EiIth4v^ 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 ' 1 day of 20��
Seal
My commission expires 34U_