NCC243451_FRO Submitted_20241107

onvi//e City of Jacksonville
c
iti ti0
•
_ Erosion and Sedimentation Control Application
I�•,M•T `t
1. Applicant(s): O'Reilly Automotive Stores Inc
Address: 233 S Patterson Ave,Springfield,MO 65802
Phone Number: [phone]
Interest in property: Developer
(Owner, developer, registered agent, manager, etc.)
2. ePlan Applicant Info: (Information of the person who will be uploading documents to ep/an)
First Name: Oliver Last Name: Kaija
Email Address: [e-mail]
3. Owner of Pro e O'Reilly Automotive Stores Inc
p rty:
(If not the applicant)
Address: 233 5 Patterson Ave,Springfield,MO 65802
Fax Number: Email: [e-mail]
4. Description of property:
a. Location of Property/Address: 6901 Western Blvd,Jacksonville,NC 28546
b. Onslow County Deed Book: 5524 Page Number: 551
c. Onslow County Map Book: 47 Page Number: 134
d. Total Acreage in Tract: 1.309 Acres
e. Acreage to be Disturbed: 1.37 ACRES
5. Submit the following documentation to Planning and Permitting:
a. One original fully executed Financial Responsibility/Ownership Form. (Attachment A)
b. One copy of a completed checklist along with all required information and documentation.
(Attachment B)
c. Check made out to the CITY OF JACKSONVILLE for the total amount due.
($225 for first acre plus $125 for every additional acre or portion thereof based on the
total disturbed acreage in the tract.)
d. Upload to eplan - Erosion control plan(s) along with all related details, calculations, and
documents as required on the checklist.
Signature of Property Owner or Applicant Date

(ATTACHMENT A)
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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name: O'Reilly Auto Parts - Jacksonville, NC #4 (JL4)
2. Location of land-disturbing activity: Onslow County City or Township: City of Jacksonville
Highway/Street: Western Blvd/Williamsburg Pkw' Latitude: 34° Longitude: -77°
3. Approximate date land-disturbing activity will commence: July 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
1.37 ACRES
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $ 350.00
The application fee of$225.00 for the first acre plus $125 for every additional acre (rounded up to the
next acre) is assessed without a ceiling amount. (Example: 6.4-acre application fee is$975).
7. Has an erosion and sediment control plan been filed? Yes ❑✓ No ❑ Enclosed ❑✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name: Oliver Kaija E-mail Address: [e-mail]
Telephone #: [phone] Cell #: [phone] Fax#:
9 4130 Parklake Ave, Suite 200 4130 Parklake Ave, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
10. Deed Book: 5524 Page Number: 551 (Provide a copy of the most current deed)
Part B.
1. Person(s) or firm(s)who are financially responsible for the land-disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
O'Reilly Automotive Stores, Inc.
Name E-mail Address
233 S Patterson Ave 233 S Patterson Ave
Current Mailing Address Current Street Address
Springfield MO Springfield MO
City State Zip City State Zip
Telephone #: Cell #: Fax#:

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
the designated North Carolina Agent:
CT Corporation System [e-mail]
Name E-mail Address
160 Mine Lake Ct, Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone #: 9148 60 Cell #: Fax#:
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #: Cell #: Fax#:
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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
Joe Edwards VP Real Estate Design and Store Installations
Ty or prin Title or Authority
_C-4 3/ 0 25�
Signature Date
I, e4 -1� c- ( _' -- ,a Notary P,.ublic of the County``of LA, )047, -
State of North rolina, hereby certify that Q E %E--f'0.L ----) appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this c'� , day of b ,L1-- - , 20 r
�`y p an2j a% KE_L\.)
(041,
Notary
p�—Mal
�-
= My commission expires /
U? f
PUB' I
eke
k ,