NCC223619_FRO Submitted_20221021

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 NIA in the blank.)
Part A. Waxhaw Town Campus
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Waxhaw
HighwaylStreet 4220VVAXHAW MARVIN RD Latitude 34.945 Longitude-80.774
& Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.89
6. Amount of fee enclosed: $ 1,000.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900,00).
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 Jeffrey Wells E-mail Address jwells@waxhaw,com
Telephone [phone] (ext 254) Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Town of Waxhaw
704-843-2195 (ext 254) 704-843-2196
Name
Telephone Fax Number
PO Box 6
1150 N. Broome St.
Current Mailing Address
Current Street Address
Waxhaw NC
28173 Waxhaw NC 28173
City State
Zip City State Zip
10. Deed Book No. 7686
Page No. 838 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Town of Waxhaw
[e-mail]
Name
E-mail Address
PO Box 6
1150 N Broome St.
Current Mailing Address
Current Street Address
Waxhaw NC
28173 Waxhaw NC 28173
City State
Zip City State Zip
Telephone[phone] (ext 254) Fax Number704-843-2196

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
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone 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.
Jeffrey Wells
Type ojrff i nyrkgl
Town Manager
Title or A thorLOZO
ZZ ���
Date
I, a Notary Public of the County of
State of North Lrolina, hereby certify that appeared
personally before me this day and being ddfy sw8rh ack owledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of Q 20 Z—
Wendy F Davenport
NOT�W6P IBLIC
Union County, NC
My Commission Expires September 10, 2022
Notary
My commission expires