HomeMy WebLinkAboutNCC221424_FRO Submitted_20220412FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
Project Name Apex Middle Regional Creek Pump Station, Force Main, & Interceptor
2. Location of land -disturbing activity: County Wake City or Township White Oak
Highway/Street Colby Chase Dr. Latitude 35.6930 Longitude-78.8243
3. Approximate date land -disturbing activity will commence: April
1. 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): municipal infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.25
6. Amount of fee enclosed: $ 1,400 The application fee of $100,00 per acre
(rounded up to the next whole acre) is assessed without a ceiling amount (e.g. an 8.2-acre application
fee is $900).
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 Michael Whitehead E-mail Address mwhiteheadCa)macgregordev.co
Telephone 919-801-3905 Cell # 919-801-3905
Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners): **Various -- all work will
be performed within existing Town of Apex Utility Easements**
Name
Current Mailing Address
City
Telephone
Current Street Address
State Zip City
10. Deed Book No. Page No.
Part B.
Fax Number
State Zip
Provide a copy of the most current deed.
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.
MFW Investments, LLC mwhiteheadCa)macgregordev.coth
Name E-mail Address
2702 Emerald Dr.
Current Mailing Address
Emerald Isle NC 28594
City State Zip
2702 Emerald Drive
Current Street Address
Emerald Isle NC 28594
City State Zip
Telephone 919-801-3905 Fax Number NA
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
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.
MichaeJ White ad Manager
Type r e Title or Authority
Signature Date
I, r6 J:bse,[aO a Notary Public of the County of _ Ults ow
State of North Carolina, hereby certify thatj8(c),abird ,W VA (A 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 5 day of
NYRA HOGELAND
Notary Public
Onslow Co., North Carolina
Pbom+nission Expires Mar. 14, 2022
Notary
My commission expires
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