HomeMy WebLinkAboutNCC221927_FRO Submitted_20220520FINANCIAL 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.
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Project Name Wiggins Road Sewer Facilities
Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street Wiggins Road & Others Latitude: 35.625522 Longitude:-80.763939
Approximate date land -disturbing activity will commence: November 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential & Industrial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 30 acres
Amount of fee enclosed: $1,950. 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 Allison Kraft, Town of Mooresville
Telephone 704-799-4066 Cell #
E-mail Address akrafta-mooresvillenc.gov
Fax # 704-662-6298
Landowner(s) of Record (attach accompanied page to list additional owners): See Attached
Name
Current Mailing Address
City
10. Deed Book No
Part B.
Telephone
Current Street Address
State Zip City
Page No.
Fax Number
State Zip
Provide a copy of the most current deed.
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.
Town of Mooresville akrafta-mooresvillenc.gov
Name E-mail Address
PO Box 878 2523 Charlotte Highway
Current Mailing Address Current Street Address
Mooresville NC 28278 Mooresville NC 28278
City State Zip City State Zip
Telephone 704-799-4066 Fax Number 704-662-6298
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.
yc.�
Type or pant a Title or Authority
Ix
Signature Dates—T
I, Lanz e_,aIlbe o- -,a Notary Public of the County of ire -del
State of North Carolina, hereby certify that & is - appeared
personally before me this day and being duly swot acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this day of ; T20
Lara C. Leadbeter
NOTARY PUBLIC ota
Seal Iredell County, NC
My commission expires f - Llj