NCC230982_FRO Submitted_20230405

FINANCIAL 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 Environment and Natural Resources. (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.
1. Project Name WT Harris/Plott Rd Water Main Project- Phases 1-3
2. Location of land-disturbing activity: County Mecklenburg City or Township Charlotte
Highway/Street E. WT Harris Blvd.. Latitude 35'11'10.0" N Longitude 80°43'47.3" W
3. Approximate date land-disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19+0.7=19.7 AC
6. Amount of fee enclosed: $1,235+$100=$1335. The application fee of $65.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Amy Vershel E-mail Address amy.vershelacharlottenc.gov
Telephone [phone] Cell# 704-962-7685 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
see attached list.
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
City of Charlotte _amy.vershelacharlottenc.gov
Name E-mail Address
5100 Brookshire Blvd. same as mailing address
Current Mailing Address Current Street Address
Charlotte NC 28216
City State Zip City State Zip
Telephone [phone] Fax Number

( |
2. (a) If the Financially Renpons,o|e Party is not resident of North Cmo|ino, give name and street address
cf the designated North Carolina Agent:
Nam6f E-mail AddrJ+ss
Current Mailing Address Current §trAeAddress
| -- ------' ------------------------
State Zip City '- [ ' Sio(n Zip
Te|ephon Fax Number
(b) If the Financially Responsible Party is u Partnership or other person engaging in business under an
assumed name, attach m copy of the Certificate of Assumed Name, If the Financially Responsible
Party ioo Corporation, give name and street address of the Registered Agent:
ailing Address Current StX�t Address
city State Zip City State Zip
/ epnon m _ Fax Number
The above information iS true and correct iO the best OfDly knowledge and belief and was provided
by Ol8 under oath (This hJ[O0 DlUSt be signed by the FiD8DCiO||y Responsible P8[SOD if an individual
or his Ott0[D8V'iO-h]Ct. 0[ ifnot an individual, by an 0ffiC8[. director, partner, or [8giSt9n3d agent with
the 8Uth0Fib/ to 8X8CUtS iDS\[UDl8niS for the FiO8DCi8||y R8SpODSih|e P8[30D). | 8g[08 to provide
CO[[8Ct8d information should there be any change in the iDfOrO8U0O provided herein.
Chief Engineer
Type TiU80[Authority
GignE���e Date «
__________________________________________________________________
. a Notary Public cf the County of �-6
State of North CUno|iD8, hereby certify that appeared
p8[S0OG||y b8f0[8 Dl8 this day and being duly Svv0[D 8CkD0Vv|8dg8d that the above f0F0 was
executed byhim.
Witness h [{8| S8a|. this '__d
Notary
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My commission expires