NCC242873_FRO Submitted_20240923

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 end 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 riot applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Hayes (508 Rob Rd)
2. Location of land-disturbing activity: CountyCumberland City or Township Stedman
Rob Rd 35.0139 -78.7285
Highway/Street Latitude(decimArdegrees) Longitude(deoma+degrees)
3. Approximate date land-disturbing activity will commence:June 14, 2024
4. Purpose of development (residential,commercial, industrial, institutional,etc.):
Residential single fan
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): ' -7
6. Amount of fee enclosed 7Q0•00 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed El No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kevin Correia E-mail Addresscorreiaconstnictionco@gmail.c:om
Phone: Office# 910-590-9362 (Paula) Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Dannie & Alisa Hayes 910-309-3703
Name Phone: Office# Mobile#
517 Rob Rd 517 Rob Rd
Current Mailing Address Current Street Address
Stedman, NC 28391 Stedman, NC 28391
City State Zip City State Zip
10. Deed Book No.9273 Page No.60 Provide a copy of the most current deed.