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HomeMy WebLinkAboutNCC223125_FRO Submitted_20220906FINANCIAL RESPONSIBILITWOWNERSHIP 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 N/A in the blank.) Part A. 1. 2. 3. 4. 5. 6. 7. 8. Project Name McMillan Manor Subdivision Location of land -disturbing activity: County Cumberland City or Township Gray's Creek Highway/Street John McMillan Road Latitude(decimal degrees) 34.8987 Longitude(decimal degrees) 78.8850 Approximate date land -disturbing activity will commence: August 15, 2022 Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.3 ac Amount of fee enclosed: $1 ,500.00 . 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. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Ben Stout E-mail Address ben@benstoutconstruction.com Phone: Office # 910-779-0019 Mobile # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Lawrence C. Smith & Oleta C. Smith Name 4944 Grays Creek Church Road Current Mailing Address Hope Mills, NC 28348 City State Phone: Office # Mobile # 4944 Grays Creek Church Road Current Street Address Hope Mills, NC 28348 Zip City State Zip 10. Deed Book No. 2636 Page No. 551 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 pa►ty(ies). Stout Land Development, LLC ben@benstoutconstruction.com Company Name E-mail Address 1786 Metromedical Drive 1786 Metromedical Drive Current Mailing Address Fayetteville, NC 28304 City State Zip Phone: Office # 910-779-0019 Current Street Address Fayetteville, NC 28304 City State Zip 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 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) (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 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 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. cA Type or t na:tq V) Signature c.A+Vl Title or Authority Date ------------------------------------------------------------------------------------------------------------------------------------ a Notary Public of the County of -�M�58&% State of North Carolina, hereby certify that /J�h��� 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 q 11�G 4ti ARY A !9,yp&ON CO� day of Re , 20 Z-, � 4nr Notary My commission expires to- 6 - ZS Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Lawrence C. Smith & Oleta C. Smith Name Phone: Office # Mobile # 4944 Grays Creek Church Road 4944 Grays Creek Church Road Current Mailing Address Current Street Address Hope Mills, NC 28348 Hope Mills, NC 28348 City State Zip City State Zip Deed Book No. 7175 Page No. 765 Provide a copy of the most current deed. Landowner 3 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State City State Zip Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State City State Zip Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State City State Zip Zip Deed Book No. Page No. Provide a copy of the most current deed.