NCC232752_FRO Submitted_20231012

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 Currituck Community Park, Phase III
2. Location of land-disturbing activity: County Currituck City or Township Crawford
Highway/Street Shortcut Rd./College Way Latitude 36.390283 Longitude -76.018545
3. Approximate date land-disturbing activity will commence: April, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Governmental
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.0 Acres
$100.00
6. Amount of fee enclosed: $ 1,000.00
. The application fee of 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 Donald "Ike" McRee, Jr. E-mail Address [e-mail]
Telephone [phone] Cell# N/A Fax# asz-a32- 35'5-1
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Currituck County 252-232-2075 AS-A.,a • 35-yt
Name Telephone Fax Number
P.O. Box 9 153 Courthouse Road, suite 306
Current Mailing Address Current Street Address
Currituck NC 27929 Currituck, NC 27929
City State Zip City State Zip
10. Deed Book No. 1062 Page No. 356 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):
Currituck County [e-mail]
Name E-mail Address
PO Box 9 153 Courthouse Road, Suite 306
Current Mailing Address Current Street Address
Currituck, NC 27929 Currituck, NC 27929
City State Zip City State Zip
Telephone [phone] Fax Number asa - aaa - 35-51

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.
Donald "Ike" McRee, Jr. County Manager
ype o rint nam Title or Authority
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/I, LeG�n (,( , a Notary Public of the County of ak.t-t-L t2
State of North Carolina, hereby certify that b a- rnt
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personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand a`q`ngtariii%seal, this' day of , 20
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Leeann Walton = / _
clurrituck County, NC= \Nota
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