NCC221008_FRO Submitted_20220310

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. Coddle Creek Raw Water Main Supply Improvements
1. Project Name
2. Location of land -disturbing activity: County Cabarrus City or Township Concord
Highway/Street Davidson HWY Latitude 35026'15.71"N Longitude 80041'55.14"W
3. Approximate date land -disturbing activity will commence: January 2022 (Upon approval)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Capital improvements project
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.15
6. Amount of fee enclosed: $ 400 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Rusty Campbell
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. See att. Ilst
Page No See att. Ilst 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.
City of Concord
Name
E-mail Address
P.O. Box 308
635 Alfred Brown Jr Court SW
Current Mailing Address
Current Street Address
Concord, NC, 28025
Concord, NC 28025
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 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 State Zip
City State Zip
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.
Larry Campbell Deputy Director of Water Resources
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