NCC241723_FRO Submitted_20240607

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 Pitt County Sheriff Office
2. Location of land-disturbing activity: County Pitt City or Township Greenville
Highway/Street New Hope Drive Latitude 35-640179 Longitude-77.367005
3. Approximate date land-disturbing activity will commence: 8/1/2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Goverment
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.18
$100.00
6. Amount of fee enclosed: $ 700.00 . The application fee of.$619-9e-per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tim Corley E-mail Address [e-mail]
Telephone [phone] Cell# n/a Fax# n/a
9. Landowner(s)of Record(attach accompanied page to list additional owners):
County of Pitt 252-902-1000 N/A
Name Telephone Fax Number
1717 W. Fifth Street 1717 W. Fifth Street
Current Mailing Address Current Street Address
Greenville, NC 27834 Greenville, NC 27834
City State Zip City State Zip
10. Deed Book No. 256 Page No. 113 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
County of Pitt N/A
Name E-mail Address
1717 W. Fifth Street 1717 W. Fifth Street
Current Mailing Address Current Street Address
Greenville, NC 27834 Greenville, NC 27834
City State Zip City State Zip
Telephone [phone] Fax Number N/A

2. (a) it the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City Stet Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
r�—
L f :e.kiNTh Ca../ Cr♦.,46J 440 i
Type or print 1.ilime Title or Authority
l( IA'
Signature Date
r
I, VIA `-+..1[L , a Notary Public of the County of PrH
State of North Carolina, hereby certify that . IC appeared
personally before me this day and being duly sworn acldnowledged that the above form was
executed by him. �, ^
Witness my hand and notarial seal, this day of Jac 1\1 , 20 ) )--
NICOLE CHERRY 6" t
NOTARY PUBLIC Notary
P' unty
Commip /.2 6 3LMy Expires 12/03/2025 Mycommission expires