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HomeMy WebLinkAboutNCC222572_FRO Submitted_20220725FINANCIAL 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 address or phone number is unavailable, place NIA in the blank.) Part A. 1. Project Name Torchwood Ditch Design 2. Location of land -disturbing activity: County New Hanover City or Township Wilmington 633 Groundwater Way 34.286900-77.818900 Highway/Street Latltude(decimal degrees) LongltUde{decimal degrees) 3. Approximate date land -disturbing activity will commence: Fall 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Improve drainage 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas}: 1 '97 6. Amount of fee enclosed: $ 200 . The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $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 Timothy Lowe E-mail Address tlowe@nhcgov.Com Phone: Office # 910.798.7117 Mobile # 513_340.0835 9. Landowner(s) of Record (attach accompanied page to list additional owners): Cape Fear Public Utility Authority nla Name Phone: Office # Mobile # 235 Government Center Drive nla Current Mailing Address Wilmington NC 28403 State City 10. Deed Book No, 5980 Current Street Address Zip City State Zip Page No.1666 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). New Hanover County tburgess@nhcgov.com Company Name E-mail Address 230 Government Center Dr Current Mailing Address Current Street Address Wilmington NC 28403 City State Zip City State Zip Phone: office # 910.798.7183 _ _ Mobile # 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 E-mail Hdoress Current Mailing Address City State Phone: Office # Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (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 State business registry: Name of Registered Agent Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State (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 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. Tim Burgess Type or name Signatur Deputy County Manager Title or Authority 7 2-Z ZPe, Z Date a Notary Public of the County of AU 40—jzLer r ° State of North Carolina, hereby certify that M � appeared personally before me this day and being duly sworn acknowledged ifiat the aboveJArm was executed by him/her. Witness my hand and notarial seal, this joi day of , 200�01)AA Vv� 0 o ry Kymberl�h G. Crowell n� O Notary Public My commission expires �S New Hanover r` C My Commission Expires