HomeMy WebLinkAboutNCC222506_FRO Submitted_20220713FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
I. Project Name The Campus at 587- Ph 1 and Ph 2 - Sanitary Sewer Extensions
2. Location of land -disturbing activity: County Wilson
City or Township Wilson
NC Hwy 58 35.6648-77.8367
Highway/Street LatltUde(decimal degrees) LongltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: May 31 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal Sewer
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.0+2.6=1 1.6 ac
6. Amount of fee enclosed $1,050 additional The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Landon Younce - Engineer E-mail Address I.younce@greeneng.com
Phone: Office # 252-237-5365 Mobile # 252-341-9513
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wilson County 252-237-1115
Name Phone: Office # Mobile #
P.O. Box1728 2201 Miller Rd South
Current Mailing Address Current Street Address
Wilson, North Carolina 27893 Wilson, North Carolina 27893
City State Zip City State Zip
10. Deed Book No. 2488 Page No. 923-925 Provide a copy of the most current deed.
Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Wilson County Properties, Inc. jlantz@wilsonedc.com
Company Name
P.O. Box 728
Current Mailing Address
Wilson, North Carolina 27893
City State
Phone: Office # 252-237-1115
E-mail Address
219 Barnes St.
Current Street Address
Wilson, North Carolina 27893
Zip City
Mobile #
State
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
i
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Green Engineering, PLLC
Engineering firm or other consultant
Landon Younce - Engineer
Individual contact person (type or print)
Lyounce@greeneng.com
E-mail Address
252-237-5365
Phone: Office # Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Jennifer Lantz
Type or print name
Corporate Secretary — Wilson County Properties
Title or Authority
5-Z3-zz-
Date
I, a Notary Public of the County of �A
State of North Carolina, hereby certify that �� „ F Lc, A 7 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal,
NOQ N .NPu4.q4 �,� �•s
20 4
�0�''�,,(ie L I C V
'L
this o13 day of )1Ll C, 20 22
I
NotaryS
My commission expires ��
Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No._
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No, Page No. Provide a copy of the most current deed.
Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #