NCC242870_FRO Submitted_20240918

Chock if this project Is ARPA-funded ❑
Attnch n copy of the Letter of Intent to Fund
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 Name4678 Corinth Rd.
'If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e g. SRP-D-ARP-0121)below under which you were approved for funding through the
Division of Water Infrastructure(DWI)
Chatham CityTownshipMoncure
2 Location of land-disturbing activity CountyChatham
or
Corinth Rd. 35.5630 Longitude 79.011
Highway/Street Latitude a a,,y, „
3 Approximate date land-disturbing activity will commence
10Sep2024
4 Purpose of development(residential.commercial.Industrial.institutional,etc)
single family reside
5 Total acreage disturbed or uncovered(including off-site borrow and waste areas)
1.74
6 Amount of fee enclosed 5200.00 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 5900)
Checks should be addressed to NCDEQ
7 Has an erosion and sediment control plan been filed', Yes m Enclosed ❑ No 0
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name
Ashley Bethea E-mail [e-mail]
Phone Office#
Mobile#[phone]
9 Landowner(s)of Record(attach accompanied page to list additional owners)
Emily Bethea 919-793-7808
Name Phone Office# Mobile#
4845 Corinth Rd. 4845 Corinth Rd.
Current Mailing Address Current Street Address
Moncure, NC 27559 Moncure, NC 27559
City State Zip City State Zip
Page Deed Book No
2023 Pa e No 0378 Provide a copy of the most current deed

Part B.
Companyties)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page )If Ow company is a solo pmpnoforship or if fhe landowners)it
an individual(s) tine namo(s)of(no ownor(s)may ho 6stod as the financially responsible perty(ros)
Emily Bethea emllybethea94@gmall corn
Company Name E-mail Address
4845 Corinth Rd 4845 Corinth Rd.
Current Mailing Address Current Street Address
Moncure, NC 27559 Moncure, NC 27559
City State Zip City State Zip
Phone Office# Mobile#[phone]
Note If the Financially Responsible Party is not the owner of the land to be disturbed include with this form
the landowners 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
Emily Bethea Property Owner
Typ p i Title or Authority 7
Si ur 1 5-i c0 26L�"
Date
I, ./ l U,i a Notary Public of the County of W.,/
= -yeaState of North Carolina,hereby certify that 1mot It appeared personally
before me this day and being duly sworn acknowledg d that t
he above form was executed by himr'her
Witness my hand and notarial seal,this I Ith dayof ,20
Q-:NOTAR y' _ No ry
l� L,• PU6��G . My commission expires 117
I/W']/ij