NCC230019_FRO Submitted_20230104

R
TIMMONS GROUP
July 29, 2022
Mr. Randall Jones, Jr., PE
NC Dept. of Environmental Quality
Division of Energy, Mineral and Land Resources
943 Washington Square Mall
Washington, NC 27889
RE: Erosion and Sediment Control Permit
Nags Head Public Works Department
Timmons Project No. 50715
Dear Mr. Jones:
1805 West City Drive p 252.621.5030
Unit E F 252.562.6974
Elizabeth City, NC 27909 www.timmons.com
Enclosed for your review and approval, please find the following items
1. Three (3) copies of the plans for the above referenced project.
2. The original and two (2) copies of the executed Financial Responsibility Form.
3. Three (3) copies of the project narrative and appendix containing: Stormwater
Calculations; Soil Data; a portion of the USGS quad map showing project location; the
FEMA FIRMette for the site; current deeds for the site.
4. A check in the amount of $600.00 for the required fee.
If you have any questions or require any additional information, please do not hesitate to contact
me at [phone].
Sincerely,
Timmons Group
Kimberly D. Hamby,
Sr. Project Manager
E
cc: file
Mr. David Ryan, Town of Nags Head
Oakley Collier Architects
ENGINEERING I DESIGN I TECHNOLOGY

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.
2.
3.
4.
5.
6.
7
Project Name Nags Head Public Works Department
Location of land -disturbing activity: County Dare City or Township Nags Head
W. Pond Ave & S. Lark Ave 35,990025-75.652084
Highway/Street LatltUde(decima� degreesy LOngltUde(decimal degrees)
Approximate date land -disturbing activity will commence: December 1, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.19
Amount of fee enclosed: $ 600.00 . 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.
Has an erosion and sediment control plan been filed? Yes 0 Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Ryan, Town Engineer E-mail [e-mail]
Phone: Office # 252.441.6221 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Nags Head 252.441.5508
Name
PO Box 99
Current Mailing Address
Nags Head, NC 27959
Phone: Office # Mobile #
5401 S. Croatan Highway
Current Street Address
Nags Head, NC 27959
City State Zip City
10. Deed Book No. 917 Page No. 811
Additional Deeds:
DB 65 PG 291
DB 471 PG 6
DB 749 PG 51
State
Zip
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).
Town of Nags Head
Company Name
PO Box 99
Current Mailing Address
Nags Head, NC 27959
City State Zip
Phone: Office # 252.441.5508
andv.aarmanOnaasheadnc.aov
E-mail Address
5401 S. Croatan Highway
Current Street Address
Nags Head, NC 27959
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
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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
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
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.
A y Garm
T pe r print na e
Signature
Town Manager, Town of Nags Head
Title or Authority
Date
Ila
O�D "�- --)-
I M► C.1-1eA I e, a Notary Public of the County of �Ck
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowled ed that the above form was executed by him/her.
Witness my hand and notarial seal, this day of OU20 oZ si
Notary
- �p� AR y My commission expires �+D — �"'Zz�
P U 6 �.�

TOWN --OF NAGS--HEA-D-
ACCOUNTS PAYABLE
J
PO BOX 99
+%+ NAGS HEAD, NC 27959
HE `' [e-mail]
*Six Hundred Dollars and 00 Cents*
ay NCDEQ
o the 943 WASHINGTON SQUARE MALL
Irder Of WASHINGTON, NC 27889
Sauthern ank Vendor Check Check
66-2581531 Number Date Number
1962 07/28/2022 205802
VOID 180 DAYS FROM DATE OF ISSUE
$600.00
11100 20 580 211'
Tbwn Manager MP
Finance DlrepW