HomeMy WebLinkAboutNCC223620_FRO Submitted_20221025FINANCIAL 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 e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name UNC Wilmington Walton Drive Student Village Recreation Facility
2. Location of land -disturbing activity: County New Hanover City or Township Wilmington
Walton Drive 34.2212 N 77.8686 W
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 07/07/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.50 acres
$1875(exprew)+$400(1_13)=$2275 (previously paid for 5-ac)
6. Amount of fee enclosed . 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, afterwhich 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 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 David Holsinger, PE E-mail Address holsingerd@uncw.edu
Phone: Office # 91 0-962-3000 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
State of North Carolina through the University of North Carolina at Wilmington 9 1 0-962-300 0
Name
601 S College Rd
Current Mailing Address
Wilmington, NC 28403
Phone: Office #
601 S College Rd
Current Street Address
Mobile #
Wilmington, NC 28403
City State Zip City
10. Deed Book No. 6474 Page No. 2656
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 name(s) of the owner(s) may be listed as the financially responsible party(ies).
State of North Carolina through the University of North Carolina at Wilmington
Company Name
601 S College Rd
Current Mailing Address
Wilmington, NC 28403
City State Zip
Phone: Office # 910-962-3761
morganm@uncw.edu
E-mail Address
601 S College -Rd
Current Street Address
Wilmington, NC 28403
City
Mobile #
State
Zip
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
Current Mailing Address
City State
Phone: Office #
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
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.
Company DBA Name
(d) 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:
McAdams
Engineering firm or other consultant
Tonya Singletary
Individual contact person (type or print)
singletaryamcadamsco.com
E-mail Address
919.287.0908
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.
Mark D Morgan
Type or print name
Signature
AVC - Facilities
Title or Authority
_? t � 0,7 z
Date
I, MCr i V'Cv � r- I Je,(5Uy1 , a Notary Public of the County of O(i`.J 0�e ;-
State of North Carolina, hereby certify that _M.Gt yj( -, 7, KAOrQau) 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 IA-rm day of O- 120
MAUREEN F NELSON
Notary Public - North Carolina
New Hanover County NOta LL�L
My Commission Expires Aug 2, 2026 ry nn
Seal My commission expires 0 2�