NCC221179_FRO Submitted_20220328

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.
Project Name 4050 Chapra Dr
2. Location of land -disturbing activity: County New Hanover
Highway/Street Chapra Dr Latitude
34.16699
City or Township Wilmington
Longitude_ -77.898742
3. Approximate date land -disturbing activity will commence: April 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
residential
1.25
6. Amount of fee enclosed: $ 200 . The application tee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Richard Garrigan
Telephone
518-331-3247
E-mail Address [e-mail]
Cell # 518-331-3247
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Richard & Nicole Garrigan 518-331-3247
Name Telephone
3806 Providence Ct same as mailing
Current Mailing Address Current Street Addres:3
Wilmington NC 28412
City State Zip
City
State
Fax Number
Zip
10. Deed Book No. Map Book #34 Page No. 79 Provide a copy of the most current deed.
Part B.
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.
Richard Garrigan [e-mail]
Name E-mail Address
3806 Providence Ct same as mailing
Current Mailing Address Current Street Address
Wilmington NC 28412
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
Fax Number
State Zip
(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
Teleph
E-mail Address
Current Street Address
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.
Richard Garrigan Owner
Type or priDt-Rame �--___ Title or Authority
03.15.2022
gnature Date
I, �C�ni l �� ���N1'I'l�l� , a Notary Public of the County of held �Llo1r
State of North Carolina, hereby certify that R1 L� �e) appeared
personally before me this day and being duly sworn acknowledged thaf the above form was executed
by him.
Witnegp,rtly'li'ar and notarial seal, thish/day of , 20oU
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y �Zy'C0M ER,r-' , �'�,: My commission expires /1-40d
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