NCC241455_FRO Submitted_20240513

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 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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Umstead State Park-Campground Improvements
2. Location of land-disturbing activity: County Wake City or Township Raleigh
Highway/Street Glenwood Avenue Latitude 35.888974 Longitude -78.753756
3. Approximate date land-disturbing activity will commence: January 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional(State Park)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
8.9 acres previously submitted + 1.0 acre this submittal=9.9 acres total
6. Amount of fee enclosed: $100 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.
$900 previously submitted + $100 this submittal =$1000 total
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jerry Howerton E-mail Address Jerry.Howerton(a�ncparks.gov
Phone: Office#: 919-707-9361 Mobile#[phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
North Carolina State Property Office 984-236-0270
Name Phone: Office# Mobile#
1321 Mail Service Center 116 West Jones Street, Room 4055
Current Mailing Address Current Street Address
Raleigh NC 27699-1321 Raleigh NC 27603-8003
City State Zip City State Zip
10. Deed Book No. 2920 Page No. 878 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)maybe listed as the financially responsible party(ies).
State of North Carolina, Div. of Parks& Rec. Jerry.Howerton(a�ncparks.gov
Company Name E-mail Address
1615 Mail Service Center 121 West Jones Street
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27699-1615
City State Zip City State Zip
Phone: Office 919-707-9322 Mobile#:
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowners 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:
NA
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:
NA
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.
Jerry Howerton Chief of Design and Construction
Type or print name Title or Authority
/d - 2- -- 2-,
nat Date
I, Att#q* M.�'npac,ts , a Notary Public of the County of LOA V_E,
State of North Carolina, hereby certify that Te2ey I-bw ei ivrJ{ 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 a3 RA day of ()c vg612 , 20,93
GELA ly, e%
_ Notary f
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Seal
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