NCC233320_FRO Submitted_20231108

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
IREDELLNo person may initiate any land-disturbing activity on one or more acres, 1/2 acre or more inside a
COUNTY NC watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning& Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name +/- 50,000-SF Distribution Facility for Watertech, Inc.
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street Taylorsville Latitude 35.816 Longitude 80.959
3. Approximate date land-disturbing activity will commence: 11/01/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12.94
6. Amount of fee enclosed: $ 2,275 . An application fee of$175.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed,a flat fee of$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Thomas Fitts E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Ken Farris Family, LLC [phone]
Name Telephone Fax Number
7215 Highway 271 S. 7215 Highway 271 S. _
Current Mailing Address Current Street Address
Fort Smith AR 72908 Fort Smith AR 72908
City State Zip City State Zip
10. Deed Book No. 2830 Page No. 1378 Provide a copy of the most current deed.
Part B.
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet):
Fitts and Goodwin, Inc. [e-mail]
Name E-mail Address
200 Cascade Pointe Ln., Ste. 101 200 Cascade Pointe Ln., Ste. 101
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State Zip City State Zip
Telephone [phone] Fax Number
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2, (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated
North Carolina Agent:
Business Filings International, Inc.
Name E-mail Address
160 Mine Lake Ct. Ste. 200 160 Mine Lake Ct. Ste. 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615 i
City State Zip City State Zip
Telephone Fax Number
(b)If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name, attach
a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, give name and street
address of the Registered Agent:
Business Filings International, Inc.
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Ste. 200 160 Mine Lake Ct. Ste. 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone Fax Number
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 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 Person). I agree to
provide corrected information should there by any change in the information provided herein.
Thoma M. Fitts, Jr. President
Type or p i-it name Title or Authority
A V
October 10, 2023
Signatu Date
I, Emma Sievert ,a Notary Public of the County of Richland
State of North Carolina, hereby certify that Thomas M. FItts, Jr. appeared personally before me this day ti
and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 10 day of October ,2023
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My commission expires ZAP, 2o32
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