NCC224024_FRO Submitted_20221205

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 Environment and Natural Resources. (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.
Project Name City of Wilson - Lower Bloomery Swamp Sewer Improvements
2. Location of land -disturbing activity: County
Highway/Street Forest Hills Road (SR 1165)
Off
City or Township
Wilson
Latitude 35.7101 ° Longitude-77.9534°
3. Approximate date land -disturbing activity will commence: January 1, 2021
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 ac.
6. Amount of fee enclosed: $ 585.00 . 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 W. Landon Younce - Engineer E-mail Address I.younce cnr.greeneng.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Wilson
Name
Post Office Box 10
Current Mailing Address
Wilson, North Carolina 27894-0010
City State Zip
252-399-2467 252-399-2453
Telephone Fax Number
1800 Herring Avenue E
Current Street Address
Wilson, North Carolina 27893
City State Zip
10. Deed Book No. 42 Page No. 76 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
City of Wilson, North Carolina
Name
Post Office Box 10
Current Mailing Address
Wilson, North Carolina 27894-0010
City State Zip
Telephone [phone]
bbass(�a7wilsonnc.org
E-mail Address
1800 Herring Avenue
Current Street Addres
Wilson, North Carolina 27893
City State Zip
Fax Number 252-399-2453

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
W.T. Bass, IV, P.E.
Type or print name
T} ov�
Signature
Public Works Director
Title or Authority
Date (
I, En" � 6 (, V , a Notary Public of the County of Vy o1S01n
State of North Carolina, hereby certify that W T �m ':2 , 't, appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this � i(0 day of SAY1 M 20�,�
NOTARY i
MY =_ Notary
COM&GRON EXPIRES
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