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Home My WebLink AboutNCC241472_FRO Submitted_20240607FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.) Part A. Project Name: Seven Lakes Subdivision Parkland Section ( Lot # 5236) *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). Is Project ARPA Funded ARPA Project Name ARPA Project # No 2. Location of land -disturbing activity: County: Moore Highway/Street: Latitude:35.255074 City or Township: Longitude:-79.612454 Approximate date land -disturbing activity will commence: 5/2012024 Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.55 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). 7. Has an erosion and sediment control plan been filed? No 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name: Scott Wilson E-mail Address: capoconstructioninc@gmail.com Phone:910-527-0797 Mobile:910-527-0797 Landowner(s) of Record: Landowner(s) of Record _ Name Email Business Phone Mobile Phone CAPO Construction, Inc. ca oconstructioninc mail.com 910-527-0797 910-527-0797 Physical Address ailina Address Street 1 city State zip Street 1 city State Zi 165 Doctor Neal Road Southern Pines N.C. 28387 165 Doctor Neal Road Southern Pines N.C. 2838Z 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 orif the landov✓ner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). Pri ary Financially Responsible Party Company Name Email Business Phone Mobile Phone CAPO Construction, Inc. ca oconstructioninc mail.com 910-527-0797 910-527-0797 Physical Address Mailing Address Street 1 city State Zip Street 1 city State Zip 165 Doctor Neal Road Southern Pines N.C. 28387 165 Doctor Neal Road Southern Pines N.C. 28387 Additional Financially- Responsible Parties 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: Registered Agent Information Name I Email Business Phone Mobile Phone Rand Newcomer ca oconstructioninc mail.com 910-527-0797 910-527-0797 Physical Address Maillinq Address Street 1 city State Zip Street 1 --gly State Zip 165 Doctor Neal Road Southern Pines N.C. 28387 165 Doctor Neal Road Southern Pines N.C. 28387 (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 North Carolina Agent Information Name Email Business Phone Mobile Phone Ph sical Address Mailing Address Street 1 city S#ate Zip Street 1 City State ? Zip Engineering/Consulting Firm Information Name Email I Business Phone Mobile Phone Johnn Glenn Tew I JohnnyT@eclsglo alinc.com 910-897-3257 919-902-1705 Physical Address Mailing Address Street 1 city State Zip Street 1 city State Zi Additional Details 1. Stream Classification: WS-Ili; Water Supply III 2. Was Express Review Requested: No 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.