HomeMy WebLinkAboutNCC242229_FRO Submitted_20240723 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. 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 Unionville-Indian Trail Pump Station Force Main Phase 1
2. Location of land-disturbing activity: County Union County City or Township City of Monroe
Highway/Street N Rocky River Road Latltude(decimal degrees)35.052127 -80.594777
Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: JUIy 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Sewer Force Main
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 1 acres
6. Amount of fee enclosed: $ 11 00.00 . 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 ❑x No D
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Richard Riser, PE E-mail Address rriser@monroenc.org
Phone: Office# (704)282-4646 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SEE ATTACHED
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
SEE ATTACHED
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).
City of Monroe /William M. Watson mwatson@monroenc.org
Company Name E-mail Address
PO Box 69 300 Cromwell St.
Current Mailing Address Current Street Address
Monroe, NC 28112 Monroe, NC 28112
City State Zip City State Zip
Phone: Office# (704) 282-4511 Mobile#
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)
(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.
William M. Watson City Manager
Type p nt ame Title or Authority
6/V U
Sign u Date
I, bn�r( K . 14c C,IS.-S , a Notary Public of the County of un I Q rl
State of North Carolina, hereby certify that VV) g n- n (V) . (10q L-5Q n appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this c 1 day of / +(LGL , 20,,,,, K •
0�3
ERY.K. y/ # Notary
NOTARY My commission expires (0 1 to-t, aoc.(o
Pi Buc •
'Vcou 4\
Land Owners:
6. Secrest Village Homeowner's
1. Charles Kenneth Tyson
Association,Inc.
5014 Myers Rd. C/O Cusick Community
Monroe,NC 28110 Management, LLC
Deed Book: 5460, Page: 725
8008 Corporate Center Dr., Suite 100
Parcel Number: 07027005J Charlotte,NC 28226
(City of Monroe Sanitary Sewer Deed Book:7400 Page:561
Easement)
Parcel Number: 08303001U
(City of Monroe Sanitary Sewer
2. Jonathan Kent Tyson
3217 Rocky River Road Easement)
Monroe,NC 28110
7. Association Inc.
Deed Book: 5460, Page: 725
#177 1829 Dickerson Blvd.
Parcel Number: 07027005A
Monroe, NC 28110
(City of Monroe Sanitary Sewer Deed Book: 3462,Page: 896
Easement)
Parcel Number: 09336474
(City of Monroe Sanitary Sewer
3. Travis Scott Moore
Easement)
3211 N Rocky River Road
Monroe, NC 28110
8. Co. Inc.
Deed Book: 6210, Page:563 Hamilton Place HOA
Parcel Number: 07030001A
1829 Dickerson Blvd. #177
(City of Monroe Sanitary Sewer Monroe,NC 28110
Easement)
Deed Book:4049, Page: 597
Parcel Number: 09336595
4. Perry Michael Crooke
(City of Monroe Sanitary Sewer
3504 Out of Bounds Dr.
Easement)
Monroe, NC 28112
Deed Book: 7945 Page:450
9. Association Inc.
Parcel Number: 07030001
#177 1829 Dickerson Blvd.
(City of Monroe Sanitary Sewer Monroe, NC 28110
Easement)
Deed Book: 3462,Page: 896
Parcel Number: 09336504
5. Shaun Cuthbertson
(City of Monroe Sanitary Sewer
3138 N Rocky River Rd.
Monroe,NC 28110 Easement)
Deed Book: 7559,Page:234
Parcel Number: 09336021E Continued on Next Page.
(City of Monroe Sanitary Sewer
Easement)
10. Association Inc. 15. James Richard Lowery
#177 1829 Dickerson Blvd. 3029 Fowler Secrest Rd.
Monroe, NC 28110 Monroe, NC 28110
Deed Book:3462,Page: 896 Deed Book: 4471,Page: 865
Parcel Number: 09336506 Parcel Number: 09295015J
(City of Monroe Sanitary Sewer (City of Monroe Sanitary Sewer
Easement) Easement)
11. Co. Inc. 16. Jacalyn M. Way
Hamilton Place HOA 3025 Fowler Secrest Rd.
1829 Dickerson Blvd. #177 Monroe, NC 28110
Monroe, NC 28110 Deed Book: 896,Page: 761
Deed Book:3462,Page: 896 Parcel Number: 09295015I
Parcel Number: 09336609 (City of Monroe Sanitary Sewer
(City of Monroe Sanitary Sewer Easement)
Easement)
17. Nancy Bost
12. Video Stop Distributing Inc. 3015 Fowler Secrest Rd.
5523 Orr Rd. Monroe, NC 28110
Monroe, NC 28110 Deed Book: 6106,Page: 0001
Deed Book:7554 Page:475 Parcel Number: 09295015A
Parcel Number: 09336269C (City of Monroe Sanitary Sewer
(City of Monroe Sanitary Sewer Easement)
Easement)
18. Teresa V. Strickland
13. Kandy A Parker 3014 James Hamilton Road
3904 Arbor Creek Ct. Monroe, NC 28110
Monroe, NC 28110 Deed Book: 4058, Page: 0659
Deed Book: 5085,Page: 0220 Parcel Number: 09295014C
Parcel Number: 09336269B (City of Monroe Sanitary Sewer
(City of Monroe Sanitary Sewer Easement)
Easement)
14. AMH NC Properties LP Continued on Next Page.
30601 Agoura Rd.,Suite 200
Agoura Hills, CA 91301
Deed Book:6970 Page:047
Parcel Number: 09336269A
(City of Monroe Sanitary Sewer
Easement)
19. Thomas Edward Davis 24. Shirley F Medlin
3006 James Hamilton Rd. 2805 Fowler Secrest Rd.
Monroe,NC 28110 Monroe,NC 28110
Deed Book: 7720,Page: 0045 Deed not found online
Parcel Number: 09295014E Parcel Number: 09295013
(City of Monroe Sanitary Sewer (City of Monroe Sanitary Sewer
Easement) Easement)
20. Erik Vivero Ramirez 25. Shirley F Medlin
1117 Kinder Oak Dr. 2805 Fowler Secrest Rd.
Indian Trail, NC 28079 Monroe,NC 28110
Deed Book: 8207 Page:827 Deed not found online
Parcel Number: 09295014D Parcel Number: 09295013B
(City of Monroe Sanitary Sewer (City of Monroe Sanitary Sewer
Easement) Easement)
21. Sumi Jung Berge 26. Sandra S. Glenn
3007 Fowler Secrest Rd. 3521 Romany Dr.
Monroe,NC 28110 Monroe, NC 28110
Deed Book: 6612 Page: 168 Deed not found online
Parcel Number: 19295015B Parcel Number: 09295012C
(City of Monroe Sanitary Sewer (City of Monroe Sanitary Sewer
Easement) Easement)
27. Anna S. Holden
22. Jeffrey A. Darr 447 Rainbow Rd.
3914 Priceton Dr. Advance NC, 27006
Monroe,NC 28110 Deed Book: 02021,Page: 0643
Deed Book: 7787, Page: 0098 Parcel Number: 09295012B
Parcel Number: 09295108 (City of Monroe Sanitary Sewer
(City of Monroe Sanitary Sewer Easement)
Easement)
23. James Guy Johnston Jr. Continued on Next Page.
3199 Greenwood
Rock Hill, SC 29730
Deed Book: 6248, Page: 582
Parcel Number: 09295014
(City of Monroe Sanitary Sewer
Easement)
28. Margarita Araveli Diaz 33. Joan Ellen Barnaby
2709 Fowler Secrest Rd. 3112 Meadowood Dr.
Monroe, NC 28110 Monroe, NC 28110
Deed Book: 04421, Page: 0218 Deed not found online
Parcel Number: 09295012A Parcel Number: 09295046
(City of Monroe Sanitary Sewer (City of Monroe Sanitary Sewer
Easement) Easement)
29. Jeffrey M. Brinn
2703 Fowler Secrest Rd. 34. Joan Ellen Barnaby
Monroe, NC 28110 3112 Meadowood Dr.
Deed Book: 3087,Page: 0772 Monroe, NC 28110
Parcel Number: 09295012F Deed not found online
(City of Monroe Sanitary Sewer Parcel Number: 09295045
Easement) (City of Monroe Sanitary Sewer
Easement)
30. David A. Gustafson
2619 Fowler Secrest Rd.
Monroe, NC 28110 35. Hugh E.Wetherall
Deed Book: 03984, Page: 0890 3202 Meadowood Ct.
Parcel Number: 09295012D Monroe, NC 28110
(City of Monroe Sanitary Sewer Deed Book: 6732 Page:289
Easement) Parcel Number: 09295044
(City of Monroe Sanitary Sewer
31. Woodlands Creek Homeowners Easement)
Association Inc.
2593 W Roosevelt Blvd. 36. Hugh E. Wetherall
Monroe, NC 28110 3202 Meadowood Ct.
Deed Book: 07317, Page: 0391 Monroe, NC 28110
Parcel Number: 09298434 Deed Book: 01705,Page: 0298
(City of Monroe Sanitary Sewer Parcel Number: 09295043
Easement) (City of Monroe Sanitary Sewer
Easement)
32. Joseph V. Youance
2620 Fowler Secrest Rd. Continued on Next Page.
Monroe,NC 28110
Deed Book: 03099,Page: 0310
Parcel Number: 09295012
(City of Monroe Sanitary Sewer
Easement)
37. Hugh E.Wetherall 42. Patrick A. Secrest
3202 Meadowood Ct. 3907 Serest Short Cut Rd.
Monroe, NC 28110 Monroe,NC 28110
Deed Book: 7861 Page:822 Deed Book:0426 Page: 777
Parcel Number: 09295042 Parcel Number: 09256001
(City of Monroe Sanitary Sewer (City of Monroe Sanitary Sewer
Easement) Easement)
38. Joseph A. Sabatino
3210 Meadowood Dr.
Monroe,NC 28110
Deed Book: 01581, Page: 0074
Parcel Number: 09295041
(City of Monroe Sanitary Sewer
Easement)
39. Roger Arnold Davis Sr.
1833 Burnsville Church Rd.
Polkton, NC 28135
Deed Book: 08275, Page: 0679
Parcel Number: 09295032
(City of Monroe Sanitary Sewer
Easement)
40. Heidi Petterson
3125 Creekwood Dr.
Monroe,NC 28110
Deed Book: 06038, Page: 0891
Parcel Number: 09298148
(City of Monroe Sanitary Sewer
Easement)
41. Sandra C.Herrin
3124 Creekwood Dr.
Monroe, NC 28110
Deed not found online.
Parcel Number: 09298147
(City of Monroe Sanitary Sewer
Easement)