NCC240738_FRO Submitted_20240314

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 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 Petree Road sidewalk
*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).
N/A
2. Location of land-disturbing activity: County Forsyth City or Township Winston-Salem
Highway/Street Petree Road Latitude(decimal degrees) 36.1307 Long itude(decimal degrees) 80.3207
3. Approximate date land-disturbing activity will commence: May 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): public sidewalk
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.41
6. Amount of fee enclosed: $ 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Wesley Kimbrell E-mail Address wesleykicityofws.orq
Phone: Office# 336-727-8063 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Winston-Salem N/A N/A
Name Phone: Office# Mobile#
P.O. Box 2511 100 E. First Street
Current Mailing Address Current Street Address
Winston-Salem, NC 27102 Winston-Salem, NC 27102
City State Zip City State Zip
10. Deed Book No. Page No. 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).
City of Winston-Salem N/A _
Company Name E-mail Address
P.O. Box 2511 100 E. First Street
Current Mailing Address Current Street Address
Winston-Salem, NC 27102 Winston-Salem, NC 27102
City State Zip City State Zip
Phone: Office# 336-727-8063 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.
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.
Patrick Pate City Manager
Type or print m Title or Authority
Signature Date
kf .)-a//
I, A.,c-c,_ k-_ WOL-\ S , a Notary Public of the County of fl -}-(.,
State of North Carolina, hereby certify that Sc%.7 r c,kc_ WL -e— 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 -. CG day of--a-Nu o,,�.) , 20 L'
(„ tar.,..r.L..,,-._ --k_ Li3c4f2D
SANDRA K WALLS Notary
i: tJ. a y Public, North Carolina
i, _�l Forsyth County
��o.N�,,`/ My C mmis ion Expires My commission expires 5 .AL-Icar)