NCC223234_FRO Submitted_20220915

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 NIA in the blank.)
Part A. FRIENDSHIP DEVELOPMENT OFFSITE UTILITIES
1. Project Name
2. Location of land -disturbing activity: CountyWake City or Township Holly Springs
Highway/Street Friendship Rd Latitude35.670077 Longitude-78.909750
3. Approximate date land -disturbing activity will commence: Spring 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 41 '4
6. Amount of fee enclosed: $ 4200 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Aaron Levitt E-mail Address [e-mail]
Telephone [phone] cell # 919-508-7884 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SEE ATTACHED
Name Telephone Fax Number
Current Mailing Address Current Street Address
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.
Town of Holly Springs Aaron. [e-mail]
Name
Current Mailing Address
Holly Springs, NC 27540
city
E-mail Address
128 S. Main St.
Current Street Address
Holly Springs, NC 27540
State Zip City
Telephone [phone]
Fax Number
State
Zip

Z. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NIA
Name
Current Mailing Address
City
Telephone
State
zi
E-mail Address
Current Street Address
City State Zip
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:
NIA
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
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.
Aaron Levitt
Type or rint na
r -
ignature
Principal Engineer
Title or Authority
,57 Z
Date
I,a Notary Public of the County of U•-e.
State of North Carolina, hereby certify that _iAO'X- a, Y-� L_Q'V t'" appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Wit n, ►R MRn 16�'�potarial seal, this
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