HomeMy WebLinkAboutNCC221304_FRO Submitted_20220405FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Neal Farm
1. Project Name
Neal
Location of land -disturbing activity: CountyROckingham City or TownshipNew Bethel
Highway/StreetNewnam Rd Latitude36.2950 Longitude-79.9361
3. Approximate date land -disturbing activity will commence:4/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1 8.1
6. Amount of fee enclosed: $35900 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCD�E/Q.
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:
NameBill Arndt E-mail Address bill.arndt@maksoninc.com
Telephone704-636-5505 cell4336-215-3941 Fax 704-636-5504
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Newnam Development, LLC 704-636-5505
Name
PO Box 540
Current Mailing Address
Greensboro, NC 27402
City
10. Deed Book No. 1612
State
704-636-5504
Telephone Fax Number
235 N. Edgeworth St.
Current Street Address
Greensboro, NC 27402
Zip City
Page No.1100, 1103
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.
Makson, Inc. bill.arndt@maksoninc.com
Name
PO Box 4197
Current Mailing Address
Salisbury, NC 28145
City State Zip
Telephone 704-636-5505
E-mail Address
434 Calhoun Street
Current Street Address
Salisbury, NC 28144
City
State
Fax Number704-636-5504
Zip
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Hugh Creed Associates, Inc., PA hca@hughcreedassociates.com
Engineering Firm or other consultant E-mail Address
Dalton Ward 336-275-9826 none
Individual contact person (type or print) Telephone 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.
E (\<J•
Type or print name
Signature
Title or Authority
Date
I, _AnncA!!k-, 'flue. Uy- , a Notary Public of the County of Luar1
State of North Carolina, hereby certify that Lt) 1I IiaM �,yj'j FA 12 C 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 day of ",14Mk 20 o�Or
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Notary
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