NCC216292_FRO Submitted_20211112

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 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 Water System Extension Project
2. Location of land -disturbing activity: County Cumberland City or Township Godwin
Highway/Street NC-82 (Burnett Rd) Latitude 35.2322 Longitude -78.6744
3. Approximate date land -disturbing activity will commence: March 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Water
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.6
6. Amount of fee enclosed: $ 650.00 . 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_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Willie Burnette, Mayor
E-mail Address [e-mail]
Telephone [phone]
Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached List
Name
Telephone Fax Number
Current Mailing Address
Current Street Address
City State
Zip City State Zip
10. Deed Book No.
Page No. Provide a copy of the most current deed.
Part B.
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):
Town of Godwin
[e-mail]
Name
E-mail Address
PO Box 10
4924 Markham Street
Current Mailing Address
Current Street Address
Godwin NC
28344 Godwin NC 28344
City State
Zip City State Zip
Telephone [phone]
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
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.
Mayor Willie Burnette Town Mayor
Type or print name Title or Authority
Signature Date
I a Notary Public of the County of C�
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 hanotarial seal, this
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