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Home My WebLink AboutNCC242795_FRO Submitted_20240912 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 NCGO1 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: Lincoln County East Side Library *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: Lincoln City or Township: Iron Station Highway/Street: NC 73 Hwy, Latitude: 35.457100 Longitude:-81.069300 3. Approximate date land-disturbing activity will commence: 11/1/2024 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 9.80 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: Larry Barthelemy E-mail Address: madelynm@adcengineering.com Phone: 8647519121 Mobile: 9. Landowner(s)of Record: Landowner(s) of Record Name Email Business Phone Mobile Phone Lincoln County john.henry@lincolncountync.gov 704-736-8478 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 353 N. Generals Lincolnton NC 28092 353 N. Generals Lincolnton NC 28092 Blvd Blvd 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 Email Business Phone Mobile Phone Lincoln County john.henry@lincolncountync.gov 704-736-8478 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 353 N. Generals Lincolnton NC 28092 353 N. Generals Lincolnton NC 28092 Blvd Blvd Additional Financially Responsible Parties _ Company Name Email Business Phone Mobile Phone Lincoln County john.henry@lincolncountync.gov 704-736-8478 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip _ 353 N. Generals Lincolnton NC 28092 353 N. Generals Lincolnton NC 28092 Blvd Blvd 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 Lincoln County john.henry@lincolncountync.gov 704-736-8478 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 353 N. Generals Lincolnton NC 28092 353 N. Generals Lincolnton NC 28092 Blvd Blvd (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 1 City State Zip Engineering/Consulting Firm Information Name Email Business Phone Mobile Phone ADC Engineering, Inc. larryb@adcengineering.com 8647519122 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 25 Woods Lake Greenville South 29607 25 Woods Lake Greenville SC 29607 Rd, Suite 210 Carolina Rd, Suite 210 Additional Details 1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water 2. Was Express Review Requested: Yes 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.