NCC222818_FRO Submitted_20220808

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 a -mail address or phone
number is unavailable, p{ace NIA in the blank.}
Part A.
1. Project Name UNION GROVE FARM POND
2. Location of land -disturbing activity: County WAYN E City or Township GREAT SWAMP
UNION GROVE Chi RD 35.5335-78.0364
Highway/Street Latitudesd�e,me� a�gr�e�] Longitude����msi degreesy
3. Approximate date land -disturbing activity will commence: MID-J U LY
4. Purpose of development (residential, commercial, industrial, institutional, etc.): PRIVATE
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5 AC
6. Amount of fee enclosed $500, $1,250. 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, after which 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 erasion and sediment control plan been filed? Yes ❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJUSTIN BARBOUR E-mail [e-mail]
Phone: office # 919-242-1267 Mobile # [phone]
8. Landowner(s) of Record (attach accompanied page to list additional owners):
BARBOUR FAMILY FARMS, LLC. 919-921-1395
10
Name
PO BOX 924
Current Mailing Address
PIKEVILLE
Phone: Office # Mobile #
2496 NC H WY 581 N
Current Street Address
NC 27863 PIKEVILLE NC 27863
City State Zip City
Deed Book No. 3473 Page No. 134
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 aame(s) of the owner(s) may be listed as the financially responsible party(ies)_
BARBOUR BROTHERS CONSTRUCTION, INC.
Company Name
PO BOX 95
Current Mailing Address
PIKEVILLE NC 27863
City State Zip
Phone: office # 919-242-1267
[e-mail]
E-mail Address
2496 NC H WY 681 N
Current Street Address
Pikeville NC 27863
City State Zip
Mobile # [phone]
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:
NIA
Name of Registered Agent
Current Mailing Address
City State
Phone: office #
NIA
E-mail Address
Current Street Address
Zip 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 State business registry:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
NIA
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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.
IN1.111
Company DBA Name
td) 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:
BRYAN K JONES CONSULTING ENGINEERS, PA
Engineering firm or other consultant
BRYAN JONES
Individual contact person (type or print)
bkjones aanc.rr.com
E-mail Address
919-221-5222 919-221-5222
Phone: Office # 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_
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Type or print name
S ture
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Title or Authority
21 a
Date
1, 13rLI dtey RG a Notary Public of the County of Wain c
State of North Carolina, -} hereby certify that VS-�jri 6ar-bOUr- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by himlher.
Witness my hand and notarial seal, this 21" day of J U rl Q 20 22
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Notary
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