NCC223458_FRO Submitted_20221006

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameProposed 30", 36" and 42" Water Main - Craig Avenue Section
2. Location of land -disturbing activity: County Mecklenburg City or Township Charlotte
Highway/StreetCralg Ave Latitude(decimaidegrees)35.1875 Longitude(decimaidegrees)-80.7841
3. Approximate date land -disturbing activity will commence:OCtober 11 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal Water
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2.391 acres
6. Amount of fee enclosed: $ 300.00 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameRob Stout E-mail Address Rob. Stout pOstantec.com
Phone: Office # 704-297-7656 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Charlotte Mecklenburg Board of Education 980-343-3000 N/A
Name Phone: Office # Mobile #
701 East 2nd Street 3903 Craig Avenue (PID 15716612)
Current Mailing Address Current Street Address
Charlotte NC 28202 Charlotte NC 28211
City State Zip City State Zip
2286
10. Deed Book No. Page No. 216
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 names) of the owners) may be listed as the financially responsible party(ies).
City of Charlotte
Company Name
600 East 4th Street
Current Mailing Address
Charlotte NC 28202
[e-mail]
E-mail Address
5100 Brookshire By
Current Street Address
Charlotte NC 28216
City State Zip City State Zip
Phone: Office # 704-336-1077 Mobile # [phone]
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:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip City State Zip
Phone: Office # N/A Mobile # N/A
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office # N/A
N/A
Mobile # N/A
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
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DBA Name
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.
Jose h C. Wilson
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Chief Engineer
Title or Authority
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State of North Carolina, hereby certify that 30myn L w&so v-) 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, this day of U0 , 20 ZZ
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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.
Landowner 2 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.
Landowner 3 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.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Name
State Zip
Provide a copy of the most current deed.
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 B 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
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Zip
State Zip