NCC233751_FRO Submitted_20231220

Check if this project is ARPA-funded ❑
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 NCGO1 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 Gravity Sewer Connector (H IBS Wolfspeed)
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Chatham Slier City ETJ(Unincorporated)
2. Location of land-disturbing activity: County City or Township
Highway/Street US 64 W Latitude(decimal degrees)35.751 LOngltUde(decimal degrees)-79 C C
J4J
3. Approximate date land-disturbing activity will commence: November 2023
•
4. Purpose of development (residential, commercial, industrial, institutional, etc. :
5. Total acreage disturbed or uncovered (including off-site borrow and waste ar s): 7.99 acres
6. Amount of fee enclosed: $0 The application fee of$100.00 per acre roun e
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 E Enclosed ❑x No E
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Wes Feinman E-mail Address wes.feinman@a whiting-turner.com
Phone: Office# 919-256-6460 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Tim's Farm & Forestry LLC 336-362-2026 336-362-2026
Name Phone: Office# Mobile#
7157 BOBBY JEAN RD OFF US 64 W
Current Mailing Address Current Street Address
JULIAN NC 27283 CHATHAM CO. NC 27344
City State Zip City State Zip
10 Deed Book No. 1729 Page No. 1027 Parcel ID: 12580
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).
The Whiting-Turner Contracting Company [e-mail]
Company Name E-mail Address
8529 Six Forks Road Forum IV, Suite 150 8529 Six Forks Road Forum IV, Suite 150
Current Mailing Address Current Street Address
Raleigh North Carolina 27615 Raleigh North Carolina 27615
City State Zip City State Zip
Phone: Office# 919-256-6471 Mobile# [phone]
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)

(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.
Wes Feinman Sr. Project Manager
Type or print name Title or Authority
12/8/23
Signature Date
Jennifer Kelly
a Notary Public of the County of C'CLAY,_11 (,
State of North Carolina, hereby certify that Wes Feinman ap
peared 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 08 day of December 20 23
A,, <atia
Y
Notar L qh
My commission expires iS J 1 a0"a `j
Jennifer Kelly
NOTARY PUBLIC
Franklin County,NC
My Commission Expires August 20,2027