NCC241714_FRO Submitted_20240619

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 Environmental Quality. (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 High Priority Collection System Rehabilitation
2. Location of land-disturbing activity: County Surry City or Township Elkin
Highway/Street see map w/ EC Plan Latitude 36.249304° Longitude -80.842260°
3. Approximate date land-disturbing activity will commence: April 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Sewer Rehabilitation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.18 Acres
6. Amount of fee enclosed: $ 130.00 . The application fee of$65.00 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 Nicole Johnston E-mail Address nicole.iohnston(cr�yvsa.orq
Telephone [phone] Cell# 336-366-0870 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Easements and Rights of Ways (Yadkin Valley Sewer Authority, Town of Elkin)
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A 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):
Yadkin Valley Sewer Authority nicole.iohnston(cDyvsa.orq
Name E-mail Address
500 NC Hwy 268 W 500 NC Hwy 268 W
Current Mailing Address Current Street Address
Elkin NC 28621 Elkin NC 28621
City State Zip City State Zip
Telephone [phone] Fax Number 336-835-9840

2. (a) If 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 State 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 Zip
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.
Nicole Johnston Executive Director
Type or print name Title or Authority
//o/ o;-;2.
Signature Date
I, tr)1rA-$ Ct ( . Cc e� , a Notary Public of the County of � ( ,trC
State of North Carolina, hereby certify that I\S.eCOt Q 0-011115101) appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. —�
1/4
Witness my hand and notarial seal, this I O 'day of 3.1t,�I1.Ct, , 20 aa
ok . 4 c&tvy
PORTIA Y. HAYES Notary
NOTIPIPUBLIC r .�
Wilkes County, North Carolina My commission expires a -a -atk
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