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HomeMy WebLinkAboutNCC230126_FRO Submitted_20230124FINANCIAL 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: sianowski@riversandassociates.com Telephone: 252-752-4135 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 252-8304200 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�