NCC231378_FRO Submitted_20230510

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 Main Church Rd Water Main
2. Location of land-disturbing activity: County of Davie City or Township Mocksville
Highway/St Main Church Rd S.R.1405 Latitude 35.9456709771 Longitude-80.5912992431
3. Approximate date land-disturbing activity will commence: Feb 2023
3. Purpose of development(residential, commercial, industrial, institutional, etc.): Public Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.5 ac
6. Amount of fee enclosed: $260.00 . 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 Johnny Lambert E-mail Address: jlambert(a,daviecountync.gov
Telephone [phone] Cell# [phone] Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Right-of-Way
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):
County of Davie ilambert(cc�daviecountync.gov
Name E-mail Address
298 E. Depot St. Suite 200
Current Mailing Address Current Street Address - .
Mocksville NC 27028 -
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:
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:
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.
Johnny Lambert Director of Public.Utilities
Type or print name Title or Authority
JLnature Date/l/7- 2°2
I, McAdir*._ V1. me_ baraCC Y1 , a Notary Public of the County of 1e..„
State of North Carolina, hereby certify that :5dnnnt. 1ti dYY�1�P,t 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 vith day of pu. ,20 WIt
Notary
- -Seal -_
My commission expires `4-2'0-a0O