NCC230126_FRO Submitted_20230124

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 NIA in the blank.)
Part A.
1. Project Name: New Athletic Expansion for Farmviile Central High School
2. Location of land -disturbing activity: County: Pitt City or Township: Farmville NC
Highway/Street: 3308 E. Wilson Street Latitude: 35.594118 N Longitude:-77.568705 W
3. Approximate date land -disturbing activity will commence: December 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Educational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0 AC
6. Amount of fee enclosed: $ 325.00 . 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: Steve Janowski, PE E-mail Address: [e-mail]
Telephone: [phone] extn. 232 Cell # 252-714-3002 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pitt County Board of Education
Name
1717 W.5i" Street
Current Mailing Address
Greenville NC 27834
City State Zip
252-830-4200
Telephone Fax Number
1717 W.51^ Street
Current Street Address
Greenville NC 27834
City State Zip
10. Deed Book No. 98 Page No. 99 & No. 4246 Page No. 206 Provide a
copy of the most current deed. Deed Book
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):
Pitt County Board of Education erricka0pitt.k12.nc.us
Name E-mail Address
1717 W. 5th Street 1717 W. 5th Street
Current Mailing Address Current Street Address
Greenville NC 27834 Greenville NC 27834
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.
Aaron D. Errickson Facilities Services Director
Type or print name Title or Authority
Signature Date
Stat�of North Carolina, hereby certify that (/1OYP� 'A (&�464�&O OU appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by hi M' • ,,
4�k."
Witness ti�d�{�q#axial seal, this ay o , 20��
IVU[Cliy -VZ
My commission expire I�