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HomeMy WebLinkAboutNCC223514_FRO Submitted_20221013FINANCIAL 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. Gregory Rd & BkhRd RdImprovements 1. Project Name 9 yoaacoe Road Roadway p 2. Location of land -disturbing activity: CountyBrunswick City or TownshipBelville Highway/Street Latitude Gregory Road and Backhoe Road N 34.215 Longitude W78.025 3. Approximate date land -disturbing activity will commence:January 31, 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Roadway Maintenance 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.73 ac 6. Amount of fee enclosed: $260 . 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). 7. Has an erosion and sediment control plan been filed? Yes No EnclosedX 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: NameAna Wadsworth E-mail Address awadsworth@thewootencompany.com Telephone 919-828-0531 Cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Bert Exum Name Telephone Fax Number 2024 Lynnwood Drive Current Mailing Address Current Street Address Wilmington, NC, 28403 City State Zip City State Zip 10. Deed Book No.293 Page No.941 Provide a copy of the most current deed. Part B. 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. Brunswick County Regional Water & Sewer H2Go bwalker@h2goonline.com Name E-mail Address 516 Village Rd NE 516 Village Rd NE Current Mailing Address Current Street Address Leland, NC, 28451 Leland, NC, 28451 City State Zip City Telephone910-371-9949 Fax Number State Zip 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. No •• Type or print name Signature -------------------------------------------------------------- Executive Director, H2GO Title or Authority 10-28-21 Date Lv�j a Notary Public of the County of bru ns�; ctz State of North Carolina, hereby certify that 104 GJ4 !lc�r appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this of Y* day of ocnbh.er , 20 2. 1 TNOTEARY PUBL CG Notary F&fMiarick County North Carolina M commission /d -OS- ao� 3 My Commission Expires October 5,A2023 Yexpires_