NCC241485_FRO Submitted_20240516

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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 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 NameJennings Park Sewer System Extension
*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).
N/A (APRA funds are direct from Treasury)
2. Location of land-disturbing activity: County I redell City or Township Bethany
Jennings Rd 35.852256 -80.858525
Highway/Street LatltUde(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: March 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Recreational Park
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 4.66
6. Amount of fee enclosed: $ 1 500.00 . 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 David Saleeby E-mail [e-mail]
Phone: Office# 704-878-3000 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Proposed Utility Easements&NCDOT Rights-of Way
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
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).
Iredell County [e-mail]
Company Name E-mail Address
PO Box 788 200 S. Center Street
Current Mailing Address Current Street Address
Statesville, NC 28677 Statesville, NC 28677
City State Zip City State Zip
Phone: Office# 704-878-3000 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)

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(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.
Beth Mull County Manager
Type or int name Title or Authority
•'1-•N-,_-,x2.1) 2- 21
Sign Date
I m m il fj• DI nder5 v n , a Notary Public of the County of Iredell
State of North Carolina, hereby certify that Both I" 1• M tit 11 appeared personally
before me this day and being duly sworn acknowledgedp that the aboverr /� form was executed by him/her.
Witness my hand and notarial seal, this .(JTh c
day of f el9vvo I au , 20 % •
AND
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