NCC220515_FRO Submitted_20220216

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 NIA in the blank.)
Part A.
1. Project Name Mira Branch Section Three
2. Location of land -disturbing activity: County_ Wayne City or Township New Hope Township
Highway/Street South Beston Road SR 1719 River Basin: Neuse
Latitude N 35.2994 Longitude W-77.8478
(Lat and Long given to 4 decimal places it XX.xxxx N,-YY.yyyy W. not XX xx'xx" N, -YY yy' yy" W)
3. Approximate date land -disturbing activity will commence:_ January, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.), residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.6
Amount of fee enclosed: 400 The application fee of $6590 $100 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David A.Durham E-mail Address davidadurham(fsuddenlink.net
Telephone Cell # [phone]
Fax#
Landowner(s) of Record (attach accompanied page to list additional owners):
David A. Durham 252 468-3725
Name Telephone Fax Number
677 S. Beston Road
Current Mailing Address
LaGrange NC 28661
City State Zip
Current Street Address
City State Zip
10. Deed Book No. 1208 Page No. 131 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):
David A. Durham
Name
677 S. Beston Road
Current Mailing Address
LaGrange NC 28551
City State Zip
Telephone [phone]
davidadurham suddenlink.net
E-mail Address
Current Street Address
Fax#
City State Zip

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 Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax#
(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 State Zip
Fax#
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 by any change in the information provided herein.
David A. Durham
Type or ' t name
igna ure
Owner
Title or Authority
12--15-2021
Date
I, Doris S. McFatter a Notary Public of the County of Wayne
State of North Carolina, hereby certify that David A. Durham appeared personalty before
me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 15th
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_ day of Dec. 12021
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Notary Doris 5. IVIEFatter
My commission expires January 13't'. 2026 .