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HomeMy WebLinkAboutNCC221070_FRO Submitted_20220406FINANCIAL 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 252-237-5365 Cell # Fax # 252-243-7489 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 910-640-6600 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. lr1 Witness Wsr al e t ' day of RDS LIC unty N try na My commission expires