NCC215534_FRO Submitted_20211011

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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.
1. Project Name Taxiway A Rehabilitati
2. Location of land -disturbing activity: County_Onslow City or Township_Richlands.
Highway/Street—Albert J. Ellis Road_ Latitude_34.82835 Longitude°-77.564478_
3. Approximate date land -disturbing activity will commence: September 23, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):®Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):s3.56
6. Amount of fee enclosed: $ $1,260 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
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 —Chris White, A.A.E. E-mail [e-mail]_
Telephone_910-989-3162 Cell # N1
Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_Onslow County
Name
_234 NW Corridor Bouleva
Current Mailing Address
_910-989-3000
Telephone
_234 NW Corridor Boulevard
Current Street Address
_N/A
Fax Number
_Jacksonville NC 28450 _Jacksonville NC 28450_
City State Zip City State Zip
10. Deed Book No._466 Page No._835 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.
Warne
County
Name
_234 NW Corridor Boulevard
Current Mailing Address
[e-mail]
E-mail—Address
_234 NW Corridor Boulevard
Current Street Address
_Jacksonville NC 28450_ _Jacksonville NC 28450_
City State Zip City State Zip

Telephone�91O-989-3162 Fax Number.
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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
_RS&H Architects -Engineers -Planners, Inc._ [e-mail]
Engineering Firm or other consultant E-mail Address
_Tom Slater _919-926-4101 _N/A
Individual contact person (type or print) 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.
_Christopher White, A.A.E
r'print name
( L&: n� ���
Signature
_Airport Director.
Title or Authority
` 1 I & /zo Lr
Date
I, &ydm- 'S ToNyti )Stn , a Notary
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Public of the `y Cfo�ulnt��W
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State of North Carolina, hereby certify that ,q S t U nrn- 1 t �-L appeared personally
before me this day and being duly sworn (Iacknowledged that th above
,, form was executed by him.
Witness my hand and notarial seal, this 4 �,' *"day of TvYV bO�2O_LL
SANDRA J JANSSEN "
NOTARY PUBLIC Notary
Seal ONSLOW COUNTY ,n,� � I /1
STATE OF NORTH CAROLINA My commission expires tl j �
MY COMMISSION EXPIRES 5-17-2024