NCC231030_FRO Submitted_20230414

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 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. Stormwater Pipe Replacement Public Works Facility
Project Name P
2. Location of land-disturbing activity: County Catawba City or Township Newton
Highway/Street E. 5th Street Latitude 35'6674 Longitude-81 .2190
3. Approximate date land-disturbing activity will commence:August 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):SW Pipe Replacement
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '20
6. Amount of fee enclosed: $$130'00 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name RJ Mozeley E-mail Address [e-mail]
Telephone [phone] Cell# 828-228-4230 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Newton 828-695-4265
Name Telephone Fax Number
PO Box 550 401 North Main Avenue
Current Mailing Address Current Street Address
Newton, NC 28658-0550 Newton, NC 28658
City State Zip City State Zip
10. Deed Book No.0540;0084;0555 Page No.0281;0099;0121 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.
City of Newton [e-mail]
Name E-mail Address
PO Box 550 401 North Main Avenue
Current Mailing Address Current Street Address
Newton, NC 28658 Newton, NC 28658
City State Zip City State Zip
Telephone [phone] 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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
Todd Clark City Manager
Type pri a Title or Authori
04,/ —.?0. .24021
i nature Date
I, t 1' J 1I 1 is ' OfCl , a Notary Public of the County of COO 1�e i
ix
State of North Carolina, hereby certify that )l)O C 1C-I appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. ((��
Witness my hand and notarial seal, this 3bday of � e , 20
EMI NORM PU BEEARD ErniIJ W l -C ,'"L/
CALDWELL COUNTY Notary
NO�,�AROLINA
MY COMMISSION EXPIRES 312212025 My commission expires YYWiCh a , arms