NCC232568_FRO Submitted_20230825

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Jennings Park
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Iredell City or Township Statesville
o0
Highway/Street 141 Dietz Road Latltude(decimal degrees)35.87 Longltude(decimal degrees) -80 88
3. Approximate date land-disturbing activity will commence: 8/1/23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational Park
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 21 .192
6. Amount of fee enclosed: $2'200.00 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David Saleeby E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Iredell County 704-450-1219
Name Phone: Office# Mobile#
P.O. Box 788 123 Grannis Lane
Current Mailing Address Current Street Address
Statesville NC 28687 Statesville NC 28677
City State Zip City State Zip
10. Deed Book No. 2937 Page No.2071-2074 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).
Iredell County, Attention Beth Mull [e-mail]
Company Name E-mail Address
200 S Center Street 200 S Center Street
Current Mailing Address Current Street Address
Statesville NC 28677 Statesville NC 28269
City State Zip City State Zip
Phone: Office# 704-878-3050 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 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:
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)

1
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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Stewart, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Jamey Baysinger 704-909-3503 704-575-1829
Individual contact person (type or print) Phone: Office# Mobile#
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.
Beth M. Mull Manager, Iredell County
Type o 'nt name Title or Authority
,_, ,,_,, JUhe a51910alf
Sign ur Date
I, amyl g' anderson , a Notary Public of the County of I red ell
State of North Carolina, hereby certify that geh M 't4 I4 II 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 , 20
iv e
z'sN- �•cro-Y v' Notary
il t n (� 5
Sea lRI
',- d My commission expires Ar I ��t a
'111111111110'.