NCC221724_FRO Submitted_20220504

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. S rin side Culvert Replacement
1. Project Name p g p
2. Location of land -disturbing activity: County Forsyth City or Township Clemmons
Highway/Street Springside Dr Latitude 36.03713 Longitude -80.37367
3. Approximate date land -disturbing activity will commence: May 1 , 2019
4. Purpose of development (residential, commercial, industrial, institutional, etc.): transportation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.27 ac
6. 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).
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 Mike Gunnell, P.E. E-mail Address [e-mail]
Telephone [phone] cell # 336-293-3839 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Village of Clemmons 366-766-9170 336-712-4040
Name Telephone Fax Number
3800 Dillon Industrial Drive 3800 Dillon Industrial Drive
Current Mailing Address Current Street Address
Clemmons, NC 27012 Clemmons, NC 27012
City State Zip City State Zip
10. Deed Book No. Page No. 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.
Village of Clemmons [e-mail]
Name E-mail Address
3800 Dillon Industrial Drive 3800 Dillon Industrial Drive
Current Mailing Address Current Street Address
Clemmons, NC 27012 Clemmons, NC 27012
City State Zip City State Zip
Telephone [phone] Fax Number 336-712-4040

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
Telephone
State 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.
Scott Buffkin
Type or int name
Signature
Village Manager
Title or Authority
3-/�7-i9
Date
I, )ATR IC I f\ �rI rt- a Notary Public of the County of F-O
State of North Carolina, hereby certify that jC' u-n- 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 I vl day of Mf) R01 I j , 20 19
42.
PATRICIA A. FIFE � ��
T
cr�Y PUBUC Notary
F yin ty, North Carolina
�`.Sy commission Exp1m ' ��' a19 My commission expires

The Village of Clemmons own the Right -of -Way for Springside Drive and Edgewater
Drive. The Village has drawn up easement documents and is obtaining easements
from the following property owners:
James Rhodes & Leslie Frye
6125 Parkdale Drive
Clemmons, NC 27012
Lot No 102, Block No 4264
Marvin & Shirley Crews
PO Box 278
Clemmons, NC 27102
Lot No. 004, Block No. 4264
Renee Brooks
3211 Springside Drive
Clemmons, NC 27102
Lot No. 005, Block No. 4264