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HomeMy WebLinkAboutNCC224114_FRO Submitted_20221213FINANCIAL 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. Sorrell Oaks Subdivision 1. Project Name 2. Location of land -disturbing activity: County Franklin/Granville City or Township You ngsyiIle Highway/Street SR 1147 (Holden Rd) Latitude 36.02780 Longitude-78.53740 3. Approximate date land -disturbing activity will commence: July 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29 6. Amount of fee enclosed: $ 2900.00 . 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 Jeff Grote E-mail Address Jeff@Greenpointe-Ilc.com Telephone 919.971.5200 cell # 919.971.5200 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Sorrell Oaks Investments, LLC 919.971.5200 Name Telephone Fax Number 7201 Creedmoor Rd, Ste 140 7201 Creedmoor Rd, Ste 140 Current Mailing Address Current Street Address Raleigh NC 27613 Raleigh NC 27613 City State Zip City State Zip 10. Deed Book No. 2300 Page No. 2009-201 1 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. Greenpointe L.L.C. Jeff@Greenpointe-Ilc.com Name E-mail Address 7201 Creedmoor Rd, Ste 140 7201 Creedmoor Rd, Ste 140 Current Mailing Address Current Street Address Raleigh NC 27613 Raleigh NC 27613 City State Zip City State Zip Telephone 919.971.5200 Fax Number 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 Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip Fax Number .je (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: Yem C✓U,- Name of Regis Bred Agent Current Mailing Address �01 nA' Z-76 i 3 City State Zip Telephone q) j q j, —SZCk) i e(e aacg& 4e, Ac. Corn -mail Ad ess -7Z01 CYee� h air 11cQ c5� I Current Street Address AaNC_ Zi6►'� City VState Zip Fax Numbe 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. Ty or rint n e Title or ut o ity T`7�n A" 2 2,02Z Signa D to I, a Notary Public of the County of "Jej— State of North Carolina, hereby certify that appeared personally before me this day and being duly jwdWrVacknowledged that the above form was executed by him. Witness my hand and notarial seal, this day of �t/lC�i , 202a` N O T N ; Notary Seal �'Q� z - My commission expires G 6 GBLIC "'//�UiNTYNG\����\