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HomeMy WebLinkAboutNCC224150_FRO Submitted_20221220NT#21215 FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Saw Mill Road Tract 2. Location of land -disturbing activity: County Brunswick City or Township Northwest Sawmill Rd 34.2893-78.1500 Highway/Street Latitude (decimal degrees) LOngltUde(declmal degrees) 3. Approximate date land -disturbing activity will commence: January 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 40 6. Amount of fee enclosed: $ 4,000.00 . 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 ❑x Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Thomas J. Scheetz, P.E. E-mail Address tscheetz@ntengineers.com Phone: Office # 910-287-5900 Mobile # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Meek Earth Holdings, LLC 910-791-1196 Name P.O. Box 3167 Phone: Office # Mobile # 2201 Burnett Blvd. Current Mailing Address Current Street Address Wilmington NC 28406 Wilmington NC 28401 City State Zip City State Zip 10. Deed Book No. 4918 Page No. 1 126 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). Dominion Land Corporation Company Name 2201 Burnett Blvd. Current Mailing Address Wilmington NC 28401 City State Zip Phone: Office # 910-791-1196 sancohomes@sancohomes.com E-mail Address 2201 Burnett Blvd. Current Street Address Wilmington NC 28401 City State Zip Mobile # 910-262-7392 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: Nathan S. Sanders nathan@sancohomes.com Name of Registered Agent E-mail Address P.O. Box 3167 2201 Burnett Blvd. Current Mailing Address Current Street Address Wilmington NC 28406 Wilmington NC 28401 City State Zip City State Zip 910-791-1196 910-262-7392 Phone: Office # 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 State Phone: Office # E-mail Address Current Street Address 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 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. Nathan S. Sanders President Type,,pf print name Title or Authority / A? /ate a2 ignature Date ---- j------------------------------------------------------------------------------------------------------------------------------- I, +�a 6�11 Q �Q� , a Notary Public of the County ofS— State of North Carolina, hereby certify that Nathan S. Sanders appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. Ae-1 Witness my hand and notarial seal, this day of \CkgE 20 22 _ .•e.l W HEF�',.,� Notary "Seal • • NOTARY % . My commission expires �O] • �• P �• G• UBLIC ;•