HomeMy WebLinkAboutNCC230084_FRO Submitted_20230112FINANCIAL 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. Scotts Hill Water and Sewer District Elevated Tank and Wells
1. Project Name
2. Location of land -disturbing activity: County Pender City or Township Hampstead/Topsail
17619 US 17; see 34.397; see -77.675; see
Highway/Street attached for others Latitude attached for others Longitude attached for others
3. Approximate date land -disturbing activity will commence: March 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public utility
-.
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 3.6
6. Amount of fee enclosed: $ 260.00 . 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 Kenny P. Keel E-mail Address kkeel@pendercountync.gov
Telephone 910-259-0212 Cell# N/A
Fax# 910-259-1579
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rocky Point Topsail Water and Sewer District 910-259-0212 910-259-1579
(see attached for other sites)
Name
Telephone Fax -Number
PO Box 5
805 S. Walker Street
Current Mailing Address
Current Street Address
Burgaw, NC 28425
Burgaw, NC 28425
City State
Zip city State Zip
10. Deed Book No. 1996
1
1:Z9 Page No. ' ' Provide a copy of the most current deed.
Part B. (see
attached for other sites)
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 orfinn is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Pender County Utilities
kkeel@pendercountync.gov
Name
E-mail Address
PO Box 995
805 S. Walker Street
Current Mailing Address
Current Street Address
Burgaw, NC 28425
Burgaw, NC 28425
City State
Zip city State Zip
Telephone 910-259-0212
Fax Number 910-259-1579
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.
Kenny P. Keel
Typ or print name
Signatur `
Director, Pender County Utilities & Solid Waste
Title or Authority
I ZI I /-z-
Date
a Notary Public of the County of ve-'e—
State of North Carolina, hereby certify that eil-It ��� 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 day of _Dla el�_ Ze,e , 20 -:�- /
ftRY 0 Notary
=Z My commission expires �� - /�� Q z
PUBLIC 0
Pender County Utilities
Scotts Hill Water and Sewer District Elevated Tank and Wells
Supplemental Information — Financial Responsibility/Ownership Form
Part A. Section 2.
Location of activity:
Site
Highway/Street
Latitude
Longitude
Hampstead Well Site
17619 US 17
34.397
-77.675
Hoover Well Site
between 997/715 Hoover Rd
34.383
-77.712
EMS/Fire Station 18 Tank and Well
adjacent to 11401 US 17
34.332
-77.751
Part A. Section 9.
Landowner of record:
Site
Landowner Name
Current Mailing
Current Street
Telephone
Fax
Address
Address
Hampstead
Rocky Point Topsail
805 S. Walker
Well Site
Water and Sewer
PO Box 5
Street
910-259-0212
910-259-1579
District
Burgaw, NC 28425
Hoover Well
Pender County Board
925 Penderlea Hwy
925 Penderlea Hwy
Site
of Education
Burgaw, NC 28425
Burgaw, NC 28425
910-259-2187
910-259-0133
EMS/Fire
Station 18
Pender EMS & Fire Inc.
805 Ridgewood Rd
805 Ridgewood Rd
910-259-0891
N/A
Tank and Well
Burgaw, NC 28425
Burgaw, NC 28425
Part A. Section 10.
Deed Book No./Page No.:
Site
Landowner Name
Deed Book
Page
Hampstead Well
Rocky Point Topsail Water and Sewer District
1996
159
Site
Hoover Well Site
Pender County Board of Education
4611
2701
EMS/Fire Station
18 Tank and Well
Pender EMS &Fire Inc.
4434
203