NCC215575_FRO Submitted_20211012

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: Town of Enfield — Phase 5 Water System Improvements
2. Location of land -disturbing activity: County: Halifax City or Township: Town of Enfield
Highway/Street: NC 481, NCSRs 1224 & 1155 Lat: 36°10'47" N Long: 77039'51" W
3. Approximate date land -disturbing activity will commence: June 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal/Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.50 Acres
6. Amount of fee enclosed: $130.00. The application fee of $65.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed_X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Wayne Anderson, Mayor E-mail Address: [e-mail]
Telephone: [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT and the Town of Enfield
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No.. Page No._ _ _ 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):
Name
Town of Enfield, NC
Current Mailing Address
P.O. Box 699
Enfield, NC 27823-0699
E-mail Address
[e-mail]
Current Street Address
121 Southeast Railroad Street
Enfield, NC 27823-0699
Telephone: [phone] Fax Number: 252-445-1019

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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 of Registered Agent
Current Mailing Address
City
Telephone _
State
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
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.
Wayne Anderson Mayor, Town of Enfield, NC
Type or print name Title or Authority
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Signature Date
a Notary Public of the County of 40A 1-cox
State of North Carolina, hereby certify that \1\)C1 , rye !�tnT�Vo ex- t,:) appeared
personally before me this day and being duly swo�n acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this d
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Notary
Seal
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