NCC230882_FRO Submitted_20230418

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 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Baker's Creek Sewer Outfall Replacement
2. Location of land-disturbing activity: County Bladen City or Township Town of Dublin
Highway/Street NC-87 Latitude(decimal degrees)34.6608 Longitude(decimal degrees)-78.7263
3. Approximate date land-disturbing activity will commence: April 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Utility Infrastructure
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.0 acres
6. Amount of fee enclosed: $ 200.00 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jonathan Ward E-mail Address [e-mail]
Phone: Office# 910-862-4301 Mobile# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
James & Brenda Bryan N/A N/A
Name Phone: Office# Mobile#
PO Box 485 N/A
Current Mailing Address Current Street Address
Dublin NC 28332 N/A
City State Zip City State Zip
0843 0528
10. Deed Book No. Page No. 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 or if the landowner(s)is
an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
Town of Dublin [e-mail]
Company Name E-mail Address
PO Box 36 7386 Albert Street
Current Mailing Address Current Street Address
Dublin NC 28332 Dublin NC 28332
City State Zip City State Zip
Phone: Office# 910-862-4301 Mobile# N/A
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct 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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)

(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.
N/A
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
William Alex Hursey Mayor
Type or print name Title or Authority
_ /z y r ozz-
Signature Date /
I, W� k o , a Notary Public of the Countyof a )�
� ry k„
State of North Carolina, hereby certify that I�l‘,0Nv, appeared personally
before me this day and being duly sworn acknowledged that the above for was executed by him/her.
Witness my hand and notarial seal, this a9 day of Qg.s_QMtrk., , 0 a
..R,,.O Notary
f
�,.•� ;U_ My commission expires (3 c� (o/ �D y
•
�., Pi
J g�. d�

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Paul &Virginia Brisson N/A N/A
Name Phone: Office# Mobile#
513 Chestnut Street N/A
Current Mailing Address Current Street Address
Bladenboro NC 28320 N/A
City State Zip City State Zip
Deed Book No. 0843 Page No. 0534 Provide a copy of the most current deed.
Landowner 3 of Record:
Alex & Lori Hursey N/A N/A
Name Phone: Office# Mobile#
PO Box 434 N/A
Current Mailing Address Current Street Address
Dublin NC 28332 N/A
City State Zip City State Zip
Deed Book No. 0843 Page No. 0540 & 0546 Provide a copy of the most current deed.
Landowner 4 of Record:
David Hursey N/A N/A
Name Phone: Office# Mobile#
PO Box 52 N/A
Current Mailing Address Current Street Address
Dublin NC 28332 N/A
City State Zip City State Zip
Deed Book No. 0843 Page No. 0552 Provide a copy of the most current deed.
Landowner 5 of Record:
Town of Dublin 910-862-4301 N/A
Name Phone: Office# Mobile#
PO Box 36 7386 Albert Street
Current Mailing Address Current Street Address
Dublin NC 28332 Dublin NC 28332
City State Zip City State Zip
227 784
Deed Book No. Page No. Provide a copy of the most current deed.

Landowner 6 of Record:
Jeffrey Smith N/A N/A
Name Phone: Office# Mobile #
PO Box 554 N/A
Current Mailing Address Current Street Address
Dublin NC 28332 N/A
City State Zip City State Zip
790 Deed Book No. Page No. 93 Provide a copy of the most current deed.