HomeMy WebLinkAbout2018-277 Planning - NCDEQ financial responsibility acceptance form 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_Hillsborough Area EDD Phase 1 Water and Sewer Extensions
2. Location of land-disturbing activity: County_Orange City or Township_Hillsborough
Highway/Street_1-40 & Old Hwy 86 _Latitude_360 2' 16.92" N Longitude_7906'5.58"W _
3. Approximate date land-disturbing activity will commence:_October 2018
4. Purpose of development(residential, commercial, industrial, institutional, etc.):.Extend water&sewer infrastructure
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.29 acres
6. Amount of fee enclosed: $—$520 . 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name.Christoper J. Sandt, P.E., Staff Engineer E-mail Address_csandt @orangecountync.gov
Telephone_(919)245-2583 Cell#_(919) 590-0359 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached page
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):
Bonnie Hammersley bhammersley @orangecountync.gov
Name E-mail Address
P.O. Box 8181 200 South Cameron Street
Current Mailing Address Current Street Address
Hillsborough NC 27278 Hillsborough NC 27278
City State Zip City State Zip
Telephone.(919)245-2306 Fax Number,(919)644-3004
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.
Bonnie Hammersley County Manager
Type or print name Title or Authority
Signature Date
------------------------------------------------------------------------------------------------------------------------------------
1, ;1 zt // , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged tlit the above form was
executed by him.
Witness my hand and notarial seal, this le day of jLdu 20 /
.'S' 't-���`'°�:r��f(y`ItL's:ti aer• �
r u cr
i xd�•R:./yam��
a F`
Notary
Seafifi O '
31- .` �fr ',-FPO E My commission expires
r=
I
Landowners of Record
Name: Sally A and W Allen Addison
Telephone: (919) 732-2206
Fax Number:
Current Mailing Address: PO Box 727
Hillsborough, NC 27278
Current Street Address:
Deed Book No.: 6024
Page No.: 200
Name: Christy D Bailey, et al. and John 0 Clayton
Telephone: (919) 818-5919 (Clayton)
Fax Number:
Current Mailing Address: 7510 Country Lane
Rougemont, NC 27572
Current Street Address: 7510 Country Lane
Rougemont, NC 27572
Deed Book No.: 6074
Page No.: 492
Name: Veronica and Theirry Duclay
Telephone: (631) 549-0113
Fax Number:
Current Mailing Address: 32 Greenhills Rd
Huntington Station, NY 11746
Current Street Address: 32 Greenhills Rd
Huntington Station, NY 11746
Deed Book No.: 5280(three parcels)
Page No.: 512 (three parcels)
Name: Franklin E. Garland
Telephone: (919) 593-3437
Fax Number:
Current Mailing Address: 3020 Ode Turner Rd
Hillsborough, NC 27278-9631
Current Street Address: 3020 Ode Turner Rd
Hillsborough, NC 27278-9631
Deed Book No.: 1485
Page No.: 355
Landowners of Record (continued)
Name: Edward T. Geiger and Ileen G. Moorman Trustee
Telephone: (919) 732-5531 (Geiger)
Fax Number:
Current Mailing Address: 4016 Old NC 86
Hillsborough, NC 27278
Current Street Address: 4016 Old NC 86
Hillsborough, NC 27278
Deed Book No.: 5012
Page No.: 413
Name: North Carolina Department of Transportation
Telephone: (919) 220-4750
Fax Number:
Current Mailing Address: PO Box 15580
Durham, NC 27704
Current Street Address:
Deed Book No.: 691
Page No.: 559
Name: Suzanne Upton
Telephone:
Fax Number:
Current Mailing Address: 11508 Bridgetender Dr
Richmond,VA 23233-1782
Current Street Address: 11508 Bridgetender Dr
Richmond,VA 23233-1782
Deed Book No.: No Deed Book No. listed in GIS; PB 79
Page No.: No Deed Book No. listed in GIS: PG 117