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HomeMy WebLinkAboutNCC240654_FRO Submitted_20240318 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.) P1.art A. e Project Name g Wynn W nn Farms Lot 6 2. Location of land-disturbing activity: County Chatham City or Township Highway/Street Alton King Latitude35.555138 Longitude-79.303951 3. Approximate date land-disturbing activity will commence:March 15, 2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.);Single Family Residence 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):•57 6. Amount of fee enclosed: $ 100 . The application fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac =$9b0.00). 7. Has an erosion and sediment control plan been filed? Yes No EnclosedYES 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name David C Lewis E-mail Address dclarklewis@gmail.com Telephone 704-249-7844 Cell# Fax# 9. Landowner(s)of Record (attach accompanied page to list additional owners): David Clark Lewis 704-249-7844 Name Telephone Fax Number 117 Cynthia Lane Current Mailing Address Current Street Address Pittsboro, NC 27312 City State Zip City State Zip 10. Deed Book No.2366 Page No.1091-1092 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. Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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. David C Lewis Owner Type or print na r Title or Authority +-� `�� 03/03/2024 Date I, , a Notary Public of the County of __ r State of North Carolina, hereby certify that OVid Ca4i2A Jc.., 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 /47--Clay of a G --- , 20e>257 .. )a,ta 1 -114-e--61 A PAULA ROCHELLE PETY NOTARY PUBLIC t otary , seockingham County North CarExpires Fea /� /3 r,/ n CjC/ ��(S,/' L mmission Expires Febn» � � , My commission expires ''