NCC215790_FRO Submitted_20211103

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.
1. Project Name 2020 Earthquake Damage SanitarV Sewer Repairs Project — Phase 1
2. Location of land -disturbing activity: County Alleghany City or Township Sparta
Highway/Street US Hwy 18-E. Whitehead Street. Duncan Street. Darr Street Clyde Street. Delp. Heights Street
Latitude 36.501931 Longitude-81.119753
3. Approximate date land -disturbing activity will commence:_ September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public sewer replacement
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.94 +/- acres
6. Amount of fee enclosed: $ 65.00 . 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_X_ Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eddie Turner E-mail Address eturner(cDthelanegroupinc.com
Telephone [phone] Cell # 276.237.9381 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Various Landowners along sewer lines
Name Telephone
Current Mailing Address
City State
10. Deed Book No.
Current Street Address
Zip City
Page No.
Fax Number
State
Zip
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.
Town of Sparta spa anirwilmoth sk best.com
Name E-mail Address
P.O. Box 99 SAME
Current Mailing Address Current Street Address
Sparta NC 28675 SAME
City State Zip City State Zip
Telephone [phone] Fax Number 336.372.2051

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
Telephone
State Zip 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.
Ryan Wilmoth Town Manager _
Type or print ame Title or Authority
1, _Ore R� ldc��h:o� —,a Notary Public of the County of
State of North Carolina, hereby certify that i�utSp 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 10 day of , 20 a
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