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Home My WebLink AboutNCC230084_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