HomeMy WebLinkAboutNCC231089_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