NCC242119_FRO Submitted_20240717

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 Name: Jack Warren Park Improvements
*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: Forsyth City or Township: Lewisville
Highway/Street: 440 Lewisville Clemmons Road Latitude: 36.089636 Longitude: -
80.412469
3. Approximate date land-disturbing activity will commence: 4/30/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: adding amenities
to a public park
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.80
6. 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$900).
7. Has an erosion and sediment control plan been filed? No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name:Town of Lewisville E-mail Address:
Phone: Mobile: 5-oIberk (Gtkiisvj�\cMC•Y1e.$
33(,-qqs-1Ua3
9. Landowner(s)of Record:
Landowner(s) of Record
Name .1-011)ey4 Email Business Phone Mobile Phone
Town of Lewisville }[e-mail] 33G0-Q'-Is-1023
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
440 Lewisville Lewisville North 27023 6510 Shallowford Lewisville North 27023
Clemmons Road Carolina Road Carolina

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).
Primary Financially.Responsible Party
Company Name 5tOtbevic Business Phone Mobile Phone
Town of Lewisville .leyefeQlewisvillenc.net 33(c-QqS-/Oc73
Physical Address Mailing Address
Street 1 City State Zip Street 1 City: , State. Zip -.-
440 Lewisville Lewisville North 27023 6510Shallowford Lewisville North 27023
Clemmons Road Carolina Road:' Carolina
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
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:
Registered Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State .' Zip
(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
Physical Address Mailing Address
Street 1 City State Zip Street 7 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
McGill Associates [e-mail] 8283282024
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
1240 19th Hickory NC 28601 .,1240 19th Street Hickory NC 28601
Street Lane Lane NW
NW

Additional Details
1. Stream Classification: C:Aquatic Life, Secondary Contact Recreation, Fresh water
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.
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