NCC222516_FRO Submitted_20220714

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. Druid Hills Neighborhood Park
1. Project Name
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street PoinSett Street Latitude 35.25849 Longitude-80.83096
3. Approximate date land -disturbing activity will commence: August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.93
6. Amount of fee enclosed: $ 520 . 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 Lester A. Barnes E-mail Address [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mecklenburg County
Name
Telephone Fax Number
600 E 4th Street, 11th Floor
Current Mailing Address
Current Street Address
Charlotte NC 28202
City State Zip
City State Zip
10. Deed Book No. see attachments 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.
Mecklenburg County AFM - David Booth
[e-mail]
Name
E-mail Address
3205 Freedom Drive, Suite 6000
Current Mailing Address
Current Street Address
Charlotte NC 28208
City State Zip
City State Zip
[phone]
Telephone
Fax Number

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 State
Telephone.
E-mail Address
Current Street Address
Zip City
Fax Number.
State Zip
(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
Fax Number
State Zip
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
David Booth Proiect Manager - Mecklenburg County
Type or pr name
Signature
Title or Authority
06/11/2021
Date
I , kayk Al Oawft , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seat, this f day of 34me , 20 2
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