NCC220013_FRO Submitted_20220107

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Efland EMS Station
1. Project Name
2.
Location of land -disturbing activity: County Orange City or Township Hillsborough
Highway/Street US 70 W Latitude 36.080792 Longitude -79.1761
3. Approximate date land -disturbing activity will commence: October 2021
4.
5.
6.
7.
8.
a
Purpose of development (residential, commercial, industrial, institutional, etc.): EMS Station
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.2 aC
Amount of fee enclosed: $ 195.00 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Angel Barnes E-mail Address abarnes@ orangecountync.gov
Telephone [phone] cell # 919.610.8182
Fax # N/A
Landowner(s) of Record (attach accompanied page to list additional owners):
Orange County North Carolina 919.245.2628
Name
P.O. Box 8181
Current Mailing Address
Hillsborough, NC 27278
City State Zip
10. Deed Book No. HB6539 Page No
N/A
Telephone Fax Number
300 West Tryon Street, Bldg B, 3rd Floor
Current Street Address
City
140
State
E
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Orange County North Carolina [e-mail]
Name E-mail Address
Current Mailing Address
Hillsborough, NC 27278
City
State Zip
Telephone [phone]
300 West Tryon Street, Bldg B, 3rd Floor
Current Street Address
Hillsborough, NC 27278
City State Zip
Fax Number

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 State
Teleph
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(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 State
Teleph
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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.
Type or print name
Capital Projects Manager
Title or Authority
Signature Date
------------------------------------------------------------------------------------------------------------------------------------
M , a Notary Public of the County of
State of North Carolina, hereby certify that C `� appeared
personally before me this day and being duly orn acknowledged that the above form was
executed by him.
.ttr�P�
Witness my hand and notarial seal, this _day of L)Oe 20�
—
HEATHER OOWMAN'
Notary Public • Worth:gAmlins Notary
Qrsn"linty 10
Or Commbsi" Expires p4c 8; !021 My commission expires C - E

Instructions and Fee Schedule for Completing
Applications for
Erosion Control Plan Approval;
Stormwater Management Plan (SMP) Approval;
Land Disturbing Permit (LDP); and
Statement of Ownership and Financial Responsibility
The following must be submitted as a package for a request to review an erosion control plan for land -
disturbing activities that are regulated under the Orange County Unified Development Ordinance (UDO):
1. One completed signed, and notarized Application for Erosion Control Plan Approval, Stormwater
Management Plan Approval and Land Disturbing Permit with the Statement of Ownership and Financial
Responsibility form. Use an original form or good copy; Please DO NOT fax.
2. One copy of the proposed sediment and erosion control plan drawing, prepared according to the standards
outlined in the North Carolina Division of Energy, Mineral, and Land Resources (NCDEMLR) Erosion and
Sediment Control Design Manual https://deg.ne.aov/about/divisions/energy-mineral-land-resources/energy-
mineral-land hermit-guidance/erosion-sediment-control-plaiuiin design -manual.
3. One copy of any supporting calculations and other applicable documents.
4. Application fee. Note, the land disturbing permit fee may also be paid at the time of submittal so that the
permit can be obtained when the plan approval is given, or the fee can be paid at a later time as longas s the
plan has been approved and is still valid. The expiration dates of the approvals, stated below, should be
considered when making this decision so that the land disturbing permit does not expire and the fee lost
before construction can begin.
All of the above items must be received before the application will be reviewed. The review period (30 days)
provided by UDO does not begin until all items have been received by the Erosion Control / Stormwater
Division.
Expiration of Plan Approval and Land Disturbing Permit
An approved Erosion Control Plan approval expires after 18 months if work has not begun (based on the
definition of the start of construction in the UDO). An approved Land Disturbing Permit (LDP) expires two (2)
years after the start of construction. If construction extends beyond two (2) years, another LDP must be paid.
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Instructions for Completing the Application Form
Please type or print in ink. Please Do Not Use a Pencil!
1. Name of Project: Give the name of the development, subdivision, shopping center, road, sewer line, etc. for which
the plan approval and land -disturbing permit are required. Use the same name used for other approvals.
2. Parcel Identification Numbers (PINS): What are the current PINS assigned to this property?
3. Planning Jurisdiction: What local govermnent has planning jurisdiction over this project (e.g. Carrboro, Chapel Hill,
Hillsborough, or Mebane) or is the project contained within Orange County's jurisdiction?
4. Size of Tract: How many acres are in the whole site?
5. Area Disturbed: How much area will be uncovered and/or disturbed? Give the area in both square feet and acres.
(There are 43,560 square feet in an acre.)
If one (1) acre or more will be disturbed or uncovered, the project comes under the conditions of the General Permit
of the Environmental Protection Agency's National Pollutant Discharge Elimination System (NPDES) Stormwater
Discharge, which is administered be the North Carolina Division of Energy, Mineral, and Land Resources
(NCDEMLR). In addition, the NCDEMLR Self -Inspection Program applies to projects disturbing I or more acres.
Contact the Erosion Control / Stormwater Division for details concerning the General Permit and Self -Inspection
Program.
6. Fees: Calculate the plan review fee and the land disturbing permit fee using the disturbed acreage total from 45 above.
The fees are based on the total disturbance involved including any off -site disturbances such as utility extensions,
roadway improvements, borrow and waste areas, soil stockpiles, storage yards, etc.
If the project is over the land -disturbance thresholds for the specific watershed in which the project is located; located
in either the Falls Lake Watershed (Neuse Basin); or Jordan Lake Watershed (Cape Fear Basin); and the project is
within Orange County's planning jurisdiction, a Stormwater Management Plan (SMP) is required for the project. If
an SMP is required for the project, an additional fee of $500.00 per each proposed permanent Stormwater Control
Measure (SCM) — or a flat fee of $300 for a Low Impact Development (LID) project — is added to the plan review fee
and a sealed SMP must be included with the application. See the 2020-2021 Erosion Control and Stormwater Fee
Schedule for further details on SMP review fees. Please refer to the watershed matrix or contact Orange County
Erosion Control / Stormwater to determine if an SMP and an associated SMP review fee are required.
If the project is located within the planning jurisdiction of one of the municipalities a stormwater management plan
may be required, but is administered by the specific municipal jurisdiction.
The plan review fee must accompany the application in order for the application to be considered complete and
review process to begin. LDP fees may be paid at the time of application or obtained at a later date, provided plan
approval has been granted and has not expired. However, the land disturbance cannot begin until the appropriate fee
has been paid, the LDP is obtained, a Pre -construction Conference held with Erosion Control / Stormwater personnel,
and any other applicable conditions of approval or required permits are met.
Payment by check is preferred, and checks should be made out to Orange County, NOT Orange County Erosion
Control.
Fees are subject to change; if in doubt or you have not submitted a plan recently, contact erosion control /
stormwater personnel to ensure this is the current.fee schedule. Fees are not refundable, even if the plan is never
approved, the approval or permit expires, or the proposed disturbance is never carried out.
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*2020-2021 Erosion Control and Stormwater Review Fee Schedule
Erosion Control Plan Rates and Fees: THERE IS NO MAXIMUM FEE!
Rural Disturbance: $158.00 per acre of disturbance
Urban Disturbance: $272,00 per acre of disturbance
Intense Urban Disturbance: $507.00 per acre of disturbance
Land Disturbing Permit Rates and Fees: THERE IS NO MAXIMUM FEE!
Rural Disturbance
Urban Disturbance
Intense Urban Disturbance:
$310.00 per acre of disturbance
$646.00 per acre of disturbance
$1,241.00 per acre of disturbance
Stormwater Management Plan (SMP) Review Fees:
Non -LID Projects: $500.00 per each permanent SCM
LID Projects: $300 flat fee (an additional $200 flat fee applies if a Conservation Easement is proposed)
*As applicable, the above Fees are cumulative.
Definitions for Determining Erosion Control Fees: Differences over which category to which a land -
disturbing activity belongs will be resolved by the Erosion Control / Stormwater Supervisor.
Erosion & Sedimentation Control Plan review and LDP fees are based on types of land -disturbance (rural,
urban, or intense urban disturbance) and the amount of land -disturbance. The combined rates (plan review
+ permit fees) are as follows:
➢ The Rural Disturbance Rate is applied only in unincorporated Orange County with development
proposing exempt subdivisions, minor subdivisions, single-family residential, duplex -residential and
recreational development.
➢ The Urban Disturbance Rate is applied primarily to properties inside the municipalities (Carrboro,
Chapel Hill, Durham, Hillsborough and Mebane). This urban rate also applies to non -rural
development, as described above, in unincorporated Orange County, as long as less than 50% of the
tract being developed is disturbed.
➢ The Intense Urban Disturbance Rate is applied County wide if more than 50% of the tract is disturbed,
regardless of development type.
Definitions for Determining Stormwater Management Plan (SMP) Review Fees:
A A Non -LID Project is a project in which SMP requirements will be met via the installation of permanent
SCMs, in conformance with the NCDEQ Stormwater Design Manual.
➢ An LID Project is a project in which SMP requirements will be met via the implementation of Low
Impact Development (LID) criteria as defined in Chapter 2 of the most recent version of the North
Carolina Low Impact Development Guidebook, in lieu of the installation of permanent SCMs.
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Examples of Fee Calculations:
For private road construction: Classified as a rural disturbance. The road will be approximately 1,250 feet long; the
average width of disturbance will be 30 feet (considered average clearing width for a private road). 1,250' x 30' _
37,500 square feet or 0.86 acres. The PLAN REVIEW FEE is 0.86 acres x $158.00 per disturbed acre = $135.88.
This amount must be included with the application for the review process to begin. The LDP FEE is 0.86 acres x
$310.00 per acre = $266.60, rounded to the nearest whole dollar is $267.00. This amount can be included with the
application (if construction of the project is certain), or paid prior to the start of construction.
For road construction to NCDOT standards: Classified as urban disturbance (less than 50% of the site will be
disturbed). The road will be approximately 1,250 feet long; since the entire right -of way must be cleared, the average
width of disturbance will be 50 feet. 1,250' x 50' = 62,500 square feet of 1.44 acres. The PLAN REVIEW FEE is
1.44 acres x $272.00 per disturbed acre = $391.68. This amount must be included with the application for the
review process to begin. The LAND DISTURBING PERMIT FEE is 1.44 acres x $646.00 per acre = $930.24,
This amount can be included with the application (if construction of the project is certain), or paid prior to the start of
construction.
For a non-residential site: A 0.75 acre lot involving 0.85 acres of disturbance (0.1 acre is the street right-of-way that
will be disturbed) and classified as an intense urban disturbance because more than 50% of the tract will be disturbed.
The PLAN REVIEW FEE is 0.85 acres x $507.00 per disturbed acre = $430.95, rounded to the nearest whole dollar
is $431.00. This amount must be included with the application for the review process to begin. The LAND
DISTURBING PERMIT FEE is 0.85 acres x $1,241.00 per acre = $1,054.85, rounded to the nearest whole dollar is
$1,055. This amount can be included with the application (if construction of the project is certain), or paid prior to the
start of construction.
7. Approximate Date Land Disturbance Will Begin: Give the best estimate possible regarding when the anticipated
work will begin. Per the Unified Development Ordinance, staff has 30-days for initial review following receipt of a
complete application package. Staff has 15-days to review revised plans. Therefore, for complex plan submittals, we
recommend adding 60 calendar days to your initial submittal date as a realistic expectation. This allows you and/or
your designer 15-days to turn around any required plan revisions, assuming only one round of corrections are
necessary.
8. Landowner(s) of Record: Give the requested information for all of the current owners listed on the deeds and/or
instruments listed in answer to question number 10 below. Give all of the information, including the current mailing
address, requested for each owner.
9. Future Landowner(s) (if applicable); If another person(s) or firm(s) will take possession of the property, initiate and
conduct the land disturbance, give the requested information for all of the known future owner(s) to be listed on the
deeds and/or instruments to be recorded. Give all of the information, including the current mailing address, requested
for each owner. This does not apply to subdivisions where individual lots may be sold to builders or homeowners and
it is unrealistic for the person financially responsible to know or involve these owners in advance. Example: Where a
tract is under a purchase option, show the current owner as the Landowner and the future Landowner as the developer
holding the option and developing the property (applying for subdivision approval, erosion control plan approval,
etc.).
10. Person(s) or Firm(s) Financially Responsible for the Disturbance: This can be the current owner, the developer,
the person or firm holding a lease or option on the property. This the party paying the fees for the development, land
disturbance, and construction of the property, not the building or grading contractor who will be hired to perform the
clearing and implement the erosion control plan, even though there is a contract agreement stating that the contractor
is responsible for implementing the erosion control plan. The contractor is ultimately liable to the owner/developer;
the owner/developer. The person financially responsible is liable to the County for both the implementation and
success of the approved plan. Statements on the plan that the contractor is responsible do not remove responsibility
for compliance with the UDO, and/or for enforcement actions and/or fines and penalties.
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11. Registered Agent (if any) for the Person Financially Responsible: A North Carolina agent is required if the
applicant if the applicant is not a resident of North Carolina. This may be an attorney, engineer, etc. acting as an
agent for the owner of this site.
12. Description of Land Disturbance 1 Construction: What is being built: office buildings, apartments, street, parking
lot, sewer line, etc.? List all the various components of the project.
13. Plans Prepared By: Name, mailing address, and telephone number of the person or firm that prepared the plan. In
the interest of time and effort, erosion control 1 stormwater personnel will contact this person about revisions to the
proposed plan instead of contacting the owner/developer.
14. Signature and Witness: This application and statement of ownership must be signed under oath by the financially
responsible person, if an individual or by an officer, director, partner, attorney -in -fact, or other person with authority
to execute instruments for the financially responsible person if not an individual. This form must be signed in the
presence of a Notary Public and signed and sealed by that Notary.
When and Where to Submit the Application
At least 60-d4yprior to the desired start of construction, submit the completed, signed, and notarized application
together with the plans and a check for the plan review fee (plus the Land Disturbing Permit fee, if you decide to
include it) to the address at the top of the first page of the application. Make checks payable to "Orange County".
You may ship, mail or hand deliver the plans. Please note that hand delivery does not expedite the review process.
Our policy is to review the plans in the order as they are received and deemed sufficient.
If interested in electronic plan submittal and review, please check with us as we will soon be accepting Land
Disturbing Permit applications, online payment and electronic plans via our new Citizen Self Serve (CSS) portal. The
review can be conducted electronically and, upon approval, we would require a paper copy for our files.
Review and Response to the Application
The Orange County UDO allows tip to 30 days for initial review and response to the erosion control l stormwater
management plan, followed by up to 15 day re -submittal reviews if necessary.
The plan will be reviewed and the designer contacted if there are questions or if revisions are needed. A site
investigation is normally a part of the review process. The Ordinance gives erosion control l stormwater personnel the
authority to enter the site to conduct investigations and to ensure compliance with the approved plan and Ordinance
once work begins.
The plan will be approved, approved with conditions of approval, or if disapproved, staff will discuss the needed
revisions with the designer in an effort to resolve the issues so that it can be approved. If these efforts are
unsuccessful, the plan will remain as disapproved and can be appealed at that time.
If approved, an approval packet will be sent to the financially responsible party or registered agent as supplied on the
application.
Erosion Control and Stormwater Contracts
Patrick Mallett
Erosion Control & Stormwater
[e-mail]
919-245-2577
Supervisor
Christopher Sandt, P.E.
Staff Engineer
csandt a oran eg coun nc.gov
919-245-2583
Steve Kaltenbach
Erosion Control Officer II
[e-mail]
919-245-2588
Kenneth Owens
Erosion Control Officer II
kowens(rr�oran ecountync..gov
919-245-2584
Nathan Jacobsen
Erosion Control Officer I
niacobsen(�}a,orangecountync.gov
919-245-2580
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