NCC221870_FRO Submitted_20220519

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.
1. Project Name Northampton County Courthouse
2. Location of land -disturbing activity: County Northampton City or Township Jackson
Highway/Street Us Hwy 158 Latitude 36.390285 Longitude-77.414008
3. Approximate date land -disturbing activity will commence: winter 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.22 Ac.
6. Amount of fee enclosed: $ 390 . 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 %
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Varnell E-mail Address [e-mail]
Telephone [phone] Cell # 252-382-0012 Fax # [phone]
EO
Landowner(s) of Record (attach accompanied page to list additional owners):
Northampton County 252-534-2501
Name
9467 NC Hwy 305
Current Mailing Address
Jackson, NC
City State
10. Deed Book No.47
Part B.
Telephone
9467 NC Hwy 305
Current Street Address
27845 Jackson, NC
Zip City
Page No. 12
State
252-534-2501
Fax Number
27845
Zip
Provide a copy of the most current deed.
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.
Northampton County [e-mail]
Name
9467 NC Hwy 305
Current Mailing Address
Jackson, NC 27845
City State Zip
E-mail Address
9467 NC Hwy 305
Current Street Address
Jackson, NC 27845
City State Zip

Telephone [phone] Fax Number 252-534-2501
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 State
Telephone
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 pr vided herein.
Type-or-p int name � Title or Authority
wig ature Date
Vq/rhL ( a Notary Public of the County of
State of North Carolina, hereby certify that S. 12- eV/ appeared
personally before me this day and being duly sworn acknowledged that a above form was executed
by him.
Witness my hand and notarial seal, this 2,(/ da
Seal
My commission expires