NCC241249_FRO Submitted_20240422

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 CITY OF WILSON - UPPER BLOOMERY SWAMP SEWER IMPROVEMENTS - PHASE TWO
*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 Wilson City or Township Wilson
NC Highway 42, SR 1158 35.730761 -77.975792
Highway/StreetLatitude(decimaldegrees) Longitude(decimaldegrees)
3. Approximate date land-disturbing activity will commence: 3/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Municipal Sewer
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12.0
6. Amount of fee enclosed: $ 1,200.00 . 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 W.T. Bass, IV, PE E-mail Address [e-mail]
Phone: Office# 252-399-2467 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Albert Joseph Nichols, Jr.
Name Phone: Office# Mobile#
2213 Arbor Road NW NC 42 Hwy W.
Current Mailing Address Current Street Address
Wilson, North Carolina 27893 Nichols Land 50.35 AC
City State Zip City State Zip
2321 624
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 Wilson, North Carolina [e-mail]
Company Name E-mail Address
Post Office Box 10 1800 Herring Avenue
Current Mailing Address Current Street Address
Wilson, North Carolina 27894-0010 Wilson, North Carolina 27893
City State Zip City State Zip
Phone: Office# 252-399-2467 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)

(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.
W.T. Bass, IV, PE Public Works Director
Type or print name Title or Authority
1(i` t-11i ,?__P-'1
Signature Date
I, al)riS l�ouiekle , a Notary Public of the County of WI Is°Vl
State of North Carolina, hereby certify that 1,,N1 •I• (2,ASS I V 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 'O ekOrunr�day of , 20 24
CHRISTY BOYETTE ONIA.&1, li ,Notary Public, North Carolina
Wilson County Notary
My Comnssilon Expires
April 2028 /� ,NI" -1
My commission expires n % I n , ot,0 0141

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:
Wilson County 252-399-2803
Name Phone: Office# Mobile#
P.O. Box 1728 4028 NC 42 Hwy. W.
Current Mailing Address Current Street Address
Wilson, North Carolina 27893 TR-A 50.00 AC
City State Zip City State Zip
Deed Book No. 2269 Page No. 709 Provide a copy of the most current deed.
Landowner 3 of Record:
Margaret Morris (Heirs)
Name Phone: Office# Mobile#
4153 Woodland Ct. Airport Blvd. W.
Current Mailing Address Current Street Address
Wilson, North Carolina 27893 TR-2 17.77 AC
City State Zip City State Zip
Deed Book No. 2269 Page No. 709 Provide a copy of the most current deed.
Landowner 4 of Record:
Tempie D. Pierce / Mary Jo Atkinson
Name Phone: Office# Mobile#
1715 Airport Blvd. W. Airport Blvd. W.
Current Mailing Address Current Street Address
Wilson, North Carolina 27893 Home Tract 166.90 AC
City State Zip City State Zip
Deed Book No. 2413 Page No. 482 Provide a copy of the most current deed.
Landowner 5 of Record:
U.T., Jr. and Marcia D. Williamson
Name Phone: Office# Mobile#
P.O. Box 7057 1763 Airport Blvd. W.
Current Mailing Address Current Street Address
Wilson, North Carolina 27895-7057 Haynes Land 100.13 AC
City State Zip City State Zip
2308 256
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#