NCC240324_FRO Submitted_20240214

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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.
1. ProjectNameBost Rd Sewer Improvements
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Burke City or Township Morganton
St Mary's Church Rd and Bost Rd 35.75812 -81.713497
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:5/1 5/2023
Residential and Commercial
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):8
6. Amount of fee enclosed: $800 . 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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brad Boris, Water Resources Director E-mail Address bboris [e-mail]
Phone: Office# 828-438-5285 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Morganton 828-437-8863
Name Phone: Office# Mobile#
PO Box 3448 135 Bost Rd
Current Mailing Address Current Street Address
Morganton, NC 28680 Morganton, NC 28655
City State Zip City State Zip
10. Deed Book No. 000634 Page No. 000 13 Provide a copy of the most current deed.

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).
City of Morganton [e-mail]
Company Name E-mail Address
305 E Union St. Suite A100 305 E Union St. Suite A100
Current Mailing Address Current Street Address
Morganton, NC 28655 Morganton, NC 28655
City State Zip City State Zip
Phone: Office# 828-438-5276 Mobile#
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
N/A
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.
Brad Boris Water Resources Director
Type or print name_ Title or Authority
li3
Signature Date
I, JLL)ifl e @' I( , a Not ry Public of the County of al41-
State of North Carolina, hereby certify that i/(11c I 'ri� appeared personally
before me this day and being duly sworn acknowledged that the above form was execut\)[(.614. C I I 14 t
ed him/her.
61 J
Witness my hand and notarial seal, this day of 0
`b UNe Co4%,„i
4. Notary M �/t 26( 1-/-
? Flo �0 My commission expires
. .

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:
Burke County Fair Inc
Name Phone: Office# Mobile#
145 Bost Rd 0 St Mary's Church Rd
Current Mailing Address Current Street Address
Morganton NC 28655 Morganton NC 28655
City State Zip City State Zip
Deed Book No. 715 Page No.611 Provide a copy of the most current deed.
Landowner 3 of Record:
Coffey,Christopher Jacob D/B/A Valley View Nursery
Name Phone: Office# Mobile#
PO BOX 343 0 Bost Rd
Current Mailing Address Current Street Address
COLLETTSVILLE NC 28611 Morganton NC 28655
City State Zip City State Zip
Deed Book No.2208 Page No. 783 Provide a copy of the most current deed.
Landowner 4 of Record:
WITHAWD LLC
Name Phone: Office# Mobile#
250 N Orange Ave STE 1500 115 N St Mary's Church Rd
Current Mailing Address Current Street Address
Orlando FL 32801 Morganton NC 28655
City State Zip City State Zip
Deed Book No.2352 Page No. 916 Provide a copy of the most current deed.
Landowner 5 of Record:
MCW INV LLC
Name Phone: Office# Mobile#
712 South Sterling St 826 N Green St
Current Mailing Address Current Street Address
Morganton NC 28655 Morganton NC 28655
City State Zip City State Zip
Deed Book No. 939 Page No.2090 Provide a copy of the most current deed.

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:
City of Morganton
Name Phone: Office# Mobile#
PO Box 3448 220 Catawba Meadows Dr
Current Mailing Address Current Street Address
Morganton NC 28680 Morganton NC 28655
City State Zip City State Zip
Deed Book No. 898 Page No. 711
Provide a copy of the most current deed.
Landowner 3 of Record:
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:
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 5 of Record:
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.