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HomeMy WebLinkAboutNCC230650_FRO Submitted_20230310FINANCIAL 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. Project Name SOUTH RIDGE ESTATES SUBDIVISION 2. Location of land -disturbing activity: County_Sampson City or Township_Clinton Highway/Street_Martha Lane Latltude(decimal degrees)_ 35.0228 Long ltude(decimal degrees)_-78.3513 3. Approximate date land -disturbing activity will commence:_ January 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.7 6. Amount of fee enclosed: $_1,700.00 . 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 0 Enclosed ❑ No ❑ Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name GARY WEBB Phone: Office # E-mail Address_ garywebb5400(a-)gmail.com Mobile # (910)990-4722 Landowner(s) of Record (attach accompanied page to list additional owners): MINNIE WEBB Name P.O. BOX 1133 Current Mailing Address DUNN NC 28335 City State Zip Phone: Office # Current Street Address City State _(910)990-4722 Mobile # 10. Deed Book No. 1205 Page No._361 Provide a copy of the most current deed. Zip 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). MINNIE WEBB Company Name P.O. BOX 1133 Current Mailing Address DUNN, NC 28335 City State Zip Phone: Office # _ garywebb5400(cDgmail.com E-mail Address _410 Weeks Rd. Current Street Address _DUNN, NC 28334 City State Zip Mobile # (910)990-4722 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: NA 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 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: NA 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. NA 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. Minnie Webb Type or print name Signature Owner Title or Authority Date I, , a Notary Public of the County of State of North Carolina, hereby certify that 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 day of Seal Notary My commission expires, 20 Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: NA Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: NA Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: NA Name Current Mailing Address City Deed Book No. Landowner 5 of Record Phone: Office # Current Street Address State Zip City Page No. Mobile # State Zip Provide a copy of the most current deed. NA Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties Attach copies of this page as needed to list all financially responsible parties. NA Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # NA Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # NA Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # NA Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # (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. NA 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. Minnie Webb Type or print name i Signature Owner Title or Authority Date tV �i.L'1'� a Notary Public of the County of �� Jr State of North Carolina, hereby certify that "''q �1 A i � " " � � 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 A day of aC&Ie4tr , 20 a X °py ONWNeF -, O A ARy''� UB\- .' A Notary My commission expires E �`