NCC221617_FRO Submitted_20220426

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Mitchell High School Synthetic Turf Field Project
2. Location of land -disturbing activity: County Mitchell City or Township Bakersville
Highway/Street Ledger School Rd Latitude decimal degrees) 35.972728-82.117820
( g ) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: Aprl I 15, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.4 ac
6. Amount of fee enclosed $1050 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lance Rosenberger E-mail Address [e-mail]
Phone: Office # 704-660-3000 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mitchell County Board of Education 828-766-2220
Name
72 Ledger School Rd
Current Mailing Address
Bakersville NC 28705
City State
10. Deed Book No. 147
FJhone: Office # Mobile #
72 Ledger School Rd
Current Street Address
Bakersville NC 28705
Zip City
Page No. 457
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Mitchell County Board of Education
Company Name
72 Ledger School Rd
Current Mailing Address
Bakersville NC 28705
City State
Phone: Office # 828-766-2220
E-mail Address
72 Ledger School Rd
Current Street Address
Bakersville NC 28705
Zip City
Mobile #
State
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of Stale business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If 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:
Kevin E. Herring Engineering kevin9kevinherringengineering.com
Engineering firm or other consultant
Kevin Herring PE
Individual contact person (type or print)
E-mail Address
Phone: Office #
980-621-0935
Mobile #
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Kim Hodshon Executive Director
Type or print name Title or Authority
ig ture Date
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I, �C�Oti� Jet-e-e k-- , a Notary Public of the County of M, -V -e 1
State of North Carolina, hereby certify that Y "\� OASho'r\ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 30 day of VA4 ccat,. , 20
ROBIN STREET
NOTARY PUBLIC �k
Mitchell County Notary
North Carolina
My Commissi n Expires March 2, 2027
My commission expires

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STATE OF NORTH CAROLINA
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000UVTY OP MITCHELL
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a T Ak v THIS DEED made this the 31st dayof December 1974, from C. W.
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ELLIS
and wife, IRIS G. ELLIS, of the County of Mitchell
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and State of North Carolina,)
41 hereinafter referred to as Grantors,
to WTCHEU. COt M BOARD OF EDUCATION, of
Mitchell CoantYl North Carolina, hereinafter referred to as Grantee:
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WITNESSETH•
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THAT FOR AND ]N C(3NSII'RATION of the sun of ONE HUNDRED DOLLARS
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($100.00) and other good and valuable consideration in hand paid to Grantors
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by Grantee, receipt of which is hereby 'ac]mocoledged, Grantors have bargained
and sold and do by these presents bargain, sell and convey
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unto the said
Mitchell County Board of Education, its successors or assigns,
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all that
certain tract or parcel of land situate and being in Snow Creek Township,
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Mitchell County, North Carolina, adjoining the lands of Frank Garland,
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Jarrett
Heirs, Kenneth Ellis and Grantors,
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and more particularly described as follows:
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BEGINNING on a dead Oak in the Frank Garland line, and rums
thence with said Garland line South
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790 33 Min, 10 Seca West
165.47 feet to a point in the N. C. R. R. #1193• thence with
said road South
13° 18 Min, 30 Sec. West 88.31 feet to a
point; thence South 89° 46 Min, 30 Sec, West 61.92 feet to a
point; thence South
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81° 35 Min, 30 Sec, West 75,97 feet to a
point; thence South 71° 17 Min. 30 Sec. West feet
West 5 L9:,A point
thence North 45° 44 'a
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a u s W
Min. West 85.71 feet topoint; thence
North 29° 09 Min, West 23.94 feet to a point; thence South 60° '
51 Min. West 20.00 feet
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to a
t in e branch; thence the branch the following courses and distances
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: North 29°� 9
Min. West 77.50 feet; North 31 42 Min, West 144.50 feet;
North 32° 42 Min, West 226,00 feet;
North 00 26 Min, East
62.00 feet; North 39° 00 Min. West 209.50 feet;
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North 27° 58
Min. West 64.S0 feet; North 14° 32 Min. West 7L 00 feet; North
32° 06 Min, West 80,00 feet;
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North 42° 37 Min, West 68.50 feet;
North 40 51 Min, East 100.00 feet; North 45° 47 Min. West
220.00 feet; North 27° 49 Min. East
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712,30 feet; and North 4°
48 Min, East 791.96 feet; thence leaving the branch and
Taming South 65° 43 Min.
i� m a
30 Sec. East 1061.23 feet to a point
in the line of the Jarrett Heirs; thence South 13° 37 Min. 20
Sec. West 137,03 feet to
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a point; thence South 40 26 Minx, 30 Sec.
West 438.32 feet to a point; thence South 45° 48 Min. 20 Sec, East
214.12 feet to a
point; thence South 14° 04 Min. 40 Sec. West
53,30 feet to a point; thence South 36°
W
25
feet to a point; thence South 52° 21 Min. East 53,95
feet -to 0 Sec. West 211.4
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a point; thence South 28° 23 Min. 30 Sec. East
feet to a 12 inch Maple; thence South 4` 48 Min. 40 Sec.
82.48
;
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w a.a >n
East
feet to a point; thence South 11° 13 Min, 50 Sec, West
70 .66 feet to an Oak;
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thence South 19° 00 Min. 30 Sec. East
233,73 feet to a point; thence South 70° 54 Mixi.
N a Kea
10 Sc. West
115.81 feet to a point; thence South 100 41 Min, 30 Sec. West
447,03 feet to a
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point; thence South 52° O5 Min. 30 Sec. West
168.93
and as feet to the point of beginning, containing 55,082 acresshow,
by
dated 26 November 1974�� Vaughn and Bradshaw, Surveyors,
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The foregoing conveyance is made subject to existing road and
highway, electric and telephone easements.
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