NCC230058_FRO Submitted_20230110

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.
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9
Project Name Utilities to Serve Brakebush Brothers
Location of land -disturbing activity: County Davie City or Township Mocksville
Highway/Street Eaton Road (SR 1800) & Others Latitude 35.881611 Longitude-80.540756
Approximate date land -disturbing activity will commence: April 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential & Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14 acres
Amount of fee enclosed: $910 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kenneth Gamble, Town of Mocksville E-mail Address kgamblea-mocksvillenc.gov
Telephone [phone] Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners): See Attached
Name
Current Mailing Address
City
10. Deed Book No
Part B.
Telephone
Current Street Address
State Zip City
Page No.
Fax Number
State Zip
Provide a copy of the most current deed.
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.
Town of Mocksville
Name
171 South Clement Street
Current Mailing Address
kgamblea-mocksvillenc.gov
E-mail Address
171 South Clement Street
Current Street Address
Mocksville NC 27028 Mocksville NC 27028
City State Zip City State Zip

Telephone [phone] 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 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 E-mail Address
Current Mailing 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.
Type or pri n Title or Authority
Signature Date
I, EmilL',' QlAOt!C1(,Q_ , a Notary Public of the County of _1) .V' State of of North Carolina, hereby certify that � Qinv 1¢ A-V* \ W- 6,>GUXJ& R_ 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 101 day of T� 0VLcA,\NX , 20SLI_
EMIL.Y C. QUANCE
NOTARY PUBLIC
Courdy Notary
Sear
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