The URL can be used to link to this page

Home My WebLink AboutNCC231089_FRO Submitted_20230419FINANCIAL 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_______________________________________________________________________ 2. Location of land-disturbing activity: County_________________ City or Township_________________ Highway/Street____________________ Latitude(decimal degrees)________ Longitude(decimal degrees)________ 3. Approximate date land-disturbing activity will commence:_____________________________________ 4. Purpose of development (residential, commercial, industrial, institutional, etc.):____________________ 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_________________ 6. Amount of fee enclosed: $____________________. 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 ܆ No ܆ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name________________________________ E-mail Address_______________________________ Phone: Office # ________________________ Mobile # ____________________________________ 9. Landowner(s) of Record (attach accompanied page to list additional owners): ____________________________________ ________________________ _________________ Name Phone: Office # Mobile # ____________________________________ ___________________________________________ Current Mailing Address Current Street Address ____________________________________ ___________________________________________ City State Zip City State Zip 10. Deed Book No._______________ Page No.______________ Provide a copy of the most current deed. Aberdeen US 15-501 Drive Dollar General Hoke Quewhiffle US 15-501 35.050778 -79.433817 May 1, 2023 Commercial 2.3 300 Matt Williams permits@rhetson.com 910-944-0881 859-699-8522 Thomas & Jennie Sparks, Bryan Sparks & Linda Pope 910-783-7424 3770 Beeson Dairy Road Winston Salem NC 27105 288 & 781 199 & 690 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 landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). Rhetson Companies, Inc Company Name 2075 Juniper Lake Road Current Mailing Address West End NC 27376 permits 9rhetson.com E-mail Address Current Street Address City State Zip City State Zip Phone: Office # 910-944-0881 Mobile # 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: Name of Registered Agent Current Mailing Address City State Zip Phone: Office # E-mail Address Current Street Address City State Zip 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: Name of Registered Agent Current Mailing Address City State Zip Phone: Office # E-mail Address Current Street Address Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (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 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. Type or print name Title or Authority /ZaA., -6 1 IS ig ature Date `' I, � �CO\Cf O • b,f'SGt) , a Notary Public of the County of o,( Vy.p--A4 State of North Carolina, hereby certify that 3 a&?2 S• ppeared 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 5 day of 3 Q! -�1t OL n/ , 20 o2> G; F0 otary O g t My commission expires e2: 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: ____________________________________ ________________________ _________________ Name Phone: Office # Mobile # ____________________________________ ___________________________________________ Current Mailing Address Current Street Address ____________________________________ ___________________________________________ City State Zip City State Zip Deed Book No._______________ Page No.______________ Provide a copy of the most current deed. Landowner 3 of Record: ____________________________________ ________________________ _________________ Name Phone: Office # Mobile # ____________________________________ ___________________________________________ Current Mailing Address Current Street Address ____________________________________ ___________________________________________ City State Zip City State Zip Deed Book No._______________ Page No.______________ Provide a copy of the most current deed. Landowner 4 of Record: ____________________________________ ________________________ _________________ Name Phone: Office # Mobile # ____________________________________ ___________________________________________ Current Mailing Address Current Street Address ____________________________________ ___________________________________________ City State Zip City State Zip Deed Book No._______________ Page No.______________ Provide a copy of the most current deed. Landowner 5 of Record: ____________________________________ ________________________ _________________ Name Phone: Office # Mobile # ____________________________________ ___________________________________________ Current Mailing Address Current Street Address ____________________________________ ___________________________________________ City State Zip City State Zip Deed Book No._______________ Page No.______________ Provide a copy of the most current deed. Bryan Sparks 910-783-7424 2860 NC-5 Aberdeen NC 28315 1418, 1441, 1441 40, 216, 213 Bryan Sparks 910-783-7424 2860 NC-5 Aberdeen NC 28315 1418 46 Linda Pope 910-783-7424 2860 NC-5 Aberdeen NC 28315 1418 43 & 49 Linda Pope 910-783-7424 2860 NC-5 Aberdeen NC 28315 1441 210 & 219