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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)