NCC230739_FRO Submitted_20230320

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 typo or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name
Union CCUDf«-|eSseHelms Park Water Main Extension
U�'O� VV'D��f� �[�
2. Location of�nd-d�tuddngoot�ity: Coun Union City orTovvnohi Wingate, '`^~
CUK'»afOn C'��|<� 34.9786N �04728W
Highway/Street Lohtude(dammvdegrees) Long itude(douma
December �0��
^����OU"���"_w��
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, in��insinstitutional,on�etc.): Water Main installation
� �
-,
5. Total acreage disturbed or uncovered (including off -site ^
aite borrow and waste orean):
� Acres
�
O. Amount offee enclosed: $OD
~^""^"°O0
The application fee of$1OO.ODper acre (rounded
uptothe next acre) inassessed without oceiling amount (Examp|a:8.1O-aureapplication fee is $QOO).
Checks should beaddressed toNCDEQ.
7. Has onerosion and sediment control plan been filed? Yes Enclosed Z No [l
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
l-� K8 ��
///[)O0BS /"/E]il[l . �_ thomaa.mann��uniVnoountyno.gov
Nem / E-mail Address
��n^1-�)[���_����A0 �0q-���-�1��{�
Phone: Df�ma# ' "-� "-�`- "~°�'v Mobile °°° "�^- " ' ="
Landowner(s) of Record (attach accompanied page tolist additional owners):
Union /� fo �0�1�����M0
~^OU�`� ,°-,-�°°-"°""
Nome Phone: Office # Mobile #
500 N. Main Street, Suite 600 500 N. Main Street, Suite 600
Current Mailing Address
K� �JF. ��11�
...ODFD�� ."�^ ^_^,. .^�
City State
1Az17
Current Street Address
Monroy� Y�(� �A1 1�
e .C)D R��� . ~ ~� ^�° . . "_
Zip City
A1��1
10. Deed Book No. Page No. =°-`
E.
Provide a copy of the most current deed,

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowmer(s)is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Union County
Company Name
500 N. Main Street, Suite 600
Current Mailing Address
Monroe NC 28112
E-mail Address
500 N. Main Street, Suite 600
Current Street Address
Monroe NC 28112
City State Zip City State
�0�1_�{��_���0 AO�-���-A1�{�
Phone: O�ue# ' ~ ' �~� �~~~ �obi|e# """ °�� °'°"
Note: If the Financially Responsible Party is not the owner of the land to be dishurbed, include with this form
the landowner's signed and dated written consent for the applicant to submit adraft erosion and sedimentation
control plan and toconduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name ofRegistered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Dffioe# Mobile #
Name cfIndividual to Contact (if Registered Agent isacompany)
(b) If the Financially Responsible Port' is not a resident of North Caro|ina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name ofRegistered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Offima# Mobile #
Name ofIndividual hoContact (if Registered Agent isacompany)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As, If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information kstrue and correct tOthe best Of0yknowledge 8ndbe|iefGndvv@Spr0Vded
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attOrney-iD-f@Cf' O[ifnot 8D individual, by an Ufficer, director, p8rtDe[. or registered agent with
the 8Uih0hty to execute iDStnJDleOtS for the F|O8OCiaUy FleSpODSib|e Party). | agree to provide
corrected information should there be any change inthe information provided herein.
Type Orprint name
Signature
Title or Authority
.1Z a Notary Public of the County of Z11- P­
State of North Carolina, hereby certify that L ft -appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of
Notary
I.
My commission expires whCbWAyjjm�, EXpM 10n/2025

Continued from Items 0 & 10 /n Pad A of the Financial ResponsibilitylOwnership Form for multiple
owners. Attach copies 0fthis page 88needed b}list all landowners.
Landowner 2 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 3 of Record:
Phone Office #
Current Street Address
Mobile#
Zip City State Zip
Page No. Provide a copy of the most current deed.
Name Phone Offico#
MailingCurrent
Address Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 4 of Record:
Name
Current Mailing Address
City State
Deed Book No.
Landowner 5ufRecord:
Name
Mobile#
State Zip
Provide a copy of the most current deed.
Phone: Office# PWobi|e#
Current Street Address
-----'
Zip City State Zip
Page No. Provide acopy ofthe most current deed,
Phone: Office#
Current Mailing Address Current Street Address
City State Zip City State 2]p
Deed Book No. Page No. Provide acopy ofthe most current deed,

Continued from Item Y/nPart B0fthe Financial R8Sp N0ecnhip Form for multiple parties.
Attach copies of this page 8Sneeded tolist all financially responsible parties.
Company 2Name
Current Mailing Address
E-mail Address
Current Street Address
City State 2]p City
Phone Offioe# Mobile #
Company 3Name
Current Mailing Address
City State
Phone: Office#
Company 4Name
Current Mailing Address
City State
Phone: Office #
Company 5 Name
Current Mailing Address
State Zip
E-mail Address
Current Street Address
Zip City State Zip
yWobi|e#
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Offioe# N1obika#