NCC221070_FRO Submitted_20220406

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 NIA in the blank.)
Part A.
1. Project Name Columbus County Water & Sewer District I I Water System Extensions
Location of land -disturbing activity: County Columbus City or Township Chadbourn
Highway/Street SR 1003. SR 1450 & SR 1529 Latitude 34.41916" Longitude-78.83574°
Approximate date land -disturbing activity will commence: February 14, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): County. Water
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2 ac.
6. Amount of fee enclosed: $ 200.00 . The application fee 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name W Landon Younce PE E-mail Address.__ _I.younceCEDgreeneng.com
Telephone [phone] Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NIA - Public Right -of -Way
Name
Current Mailing Address
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
10. Deed Book No. Page No. 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 an an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager maybe listed as the financially responsible party.
Columbus County, North Carolina gedwardsO)columbusco.org
Name E-mail Address
111 Washington Street 111 Washington Street
Current Mailing Address Current Street Address:
Whiteville, North Carolina 28472 Whiteville;_ ._ NMIJ;tarolina _ 28472
City State Zip City State Zip
Telephone [phone] Fax Number 910-640-1654

2. (a) If the Financially Responsible Party is not a resident of North Carolina, gi e 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 Pearson). I agree to provide
corrected information should there be any change in the information provided herein.
Edwin H. Madden, Jr. County Manager
Type or print name Ti)le\or Authority
Signature
Date
I,4;�G� , a Notary Public of the County of CtiS
State of North Carolina, hereby certify that W...�. i"l�Wrn Q appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
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