NCC221802_FRO Submitted_20220518

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. 2019 CWSRF SanitarySewer Improvements
1. Protect Namep
2. Location of land -disturbing activity: County Wilson City or Township Lucama
Highway/street see attached Latitude see attached Longitude see attached
3. Approximate date land -disturbing activity will commence: March 1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Sanitary Sewer
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 2.95
6. Amount of fee enclosed: $ 195.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Joseph McKemey E-mail [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Lucama [phone] [phone]
Name Telephone Fax Number
PO Box 127 111 South Main Street
Current Mailing Address
Current Street Address
Lucama NC 27851
Lucama NC
27851
City State Zip
City State
Zip
10, Deed Book No. See attached Page No.
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.
Town of Lucama
[e-mail]
Name
E-mail Address
PO Box 127
111 South Main Street
Current Mailing Address
Current Street Address
Lucama NC 27851
Lucama NC
27851
City State Zip
City State
Zip
Telephone [phone]
Fax Number [phone]

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 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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Jeffery Johnson
Type or print name
n re
Mayor, Town of Lucama
Title or Authority
Date
I. L ti .! �x�. pY1(�, _, a Notary Public of the County ofUzi IQnV)
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sward acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,
11-0 4F
e��aT A
ftBOO
ON COUNT
this 2811- day of 20Jj
- dv'(�'V
Notary
My commission expires It/ 2Z