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HomeMy WebLinkAboutNCC223602_FRO Submitted_20221020FINANCIAL 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 N/A in the blank.) Part A. 1. Project Name Windemere Subdivision 2. Location of land -disturbing activity: County Wayne City or Township Stoney Creek Highway/Street NCSR 1549 Combs Rd 35.447666-77.963977 LatltUde(decimal degrees} LOngltUde(decimal degrees) 3. Approximate date land -disturbing activity will commence: Sept 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.58 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 Bryan Jones E-mail Address bkjones@nC.rr.Com Phone: Office # 919-221-5222 Mobile # 919-221-5222 9. Landowner(s) of Record (attach accompanied page to list additional owners): Crosscheck Investment Group, LLC Name PO Box 216 Current Mailing Address Goldsboro, NC 27533 City 10. Deed Book No. 3716 State zip Phone: Office # Mobile # 205 Fedelon Trail Current Street Address Goldsboro, NC 27530 Zip Page No. 741 Provide a copy of the most current deed. city State 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). Crosscheck Investment Group, LLC bkjones@nc.rr.col'1'1 Company Name PO Box 216 Current Mailing Address Goldsboro, NC 27533 City State Zip Phone: office # 919-221-5222 E-mail Address 205 Fedelon Trail Current Street Address Goldsboro, NC 27530 City State Zip Mobile # 919-221-5222 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: N/A 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 Parry 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. N/A 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. N/A 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. Type 'or print Signat — Title or Authority Date I, 1 `�� �1 r, 1�c�r d , a Notary Public of the County of ,-N -Q State of North Carolina, hereby certify thatzac r z I it- K- _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 - Sealer o P [JB��� C'O •t, �'''r�.,s,..::►tits•': "`� 20 a Notary My commission expires " - 1 D ' A u