The URL can be used to link to this page

Home My WebLink About2023-082-E-Planning-Orange County-Need Bonnies signature on an NCDEMLR Erosion and sedimentation control plan application for the Gravelly Hill Middle School stormwater wetland retrofit projectRevised 06/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Orange County Party/Vendor Contact Person: Christopher Sandt (County Engineer) Contact Phone: 919-245-2583 Party/Vendor Address: 131 W. Margaret Lane, 2nd Floor City Hillsborough State: NC Zip: 27278 Department: Planning Amount: $200 (application fee) Purpose: Need Bonnie’s signature on an NCDEMLR Erosion & Sedimentation Control Plan Application for the Gravelly Hill Middle School Stormwater Wetland Retrofit Project Budget Code(s): DEAPR Account #61370035-880000-20046 Vendor # 27873 (NCDEQ) (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date February 17, 2023 Approved by Board Yes No Agenda Date: --- For Section XIV. c. contracts only, Approved by Board in Current FY Budget Yes No This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Information Technologies (Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: A6ECD43A-4359-4D26-A9B6-DA39647F9A40 2/16/2023 2/16/2023 2/16/2023 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 NCG01 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. Project Name_______________________________________________________________________ *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_________________City or Township_________________ Highway/Street____________________ Latitude(decimal degrees)________ Longitude(decimal degrees)________ 3. Approximate date land-disturbing activity will commence:_____________________________________ 4. Purpose of development (residential, commercial, industrial, institutional, etc.):____________________ 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_________________ 6. Amount of fee enclosed: $____________________. 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 ☐ Enclosed ☐ No ☐ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name________________________________ E-mail Address_______________________________ Phone: Office # ________________________ Mobile # ____________________________________ 9. Landowner(s) of Record (attach accompanied page to list additional owners): ____________________________________ ________________________ _________________ Name Phone: Office # Mobile # ____________________________________ ___________________________________________ 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. GRAVELLY HILL MIDDLE SCHOOL STORMWATER WETLAND RETROFIT ORANGE CHEEKS WEST TEN ROAD 36.07067 79.19992 6/1/2023 SCM 1.8 200 CHRISTOPHER SANDT CSANDT@ORANGECOUNTYNC.GOV 919-245-2583 512-590-0359 COUNTY OF ORANGE 919-245-2583 512-590-0359 PO BOX 8181 131 W. MARGARET LAN HILLSBOROUGH, NC 27278 HILLSBOROUGH, NC 27278 4014 24-26 DocuSign Envelope ID: A6ECD43A-4359-4D26-A9B6-DA39647F9A40 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). ____________________________________ ___________________________________________ Company Name E-mail Address ____________________________________ ___________________________________________ Current Mailing Address Current Street Address ____________________________________ ___________________________________________ City State Zip City State Zip Phone: Office # _______________________ 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: _____________________________________ ___________________________________________ Name of Registered Agent E-mail Address _____________________________________ ___________________________________________ Current Mailing Address Current Street Address _____________________________________ ___________________________________________ City State Zip City State Zip Phone: Office # ________________________ Mobile #_____________________________________ ______________________________________ 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: _____________________________________ ___________________________________________ Name of Registered Agent E-mail Address _____________________________________ ___________________________________________ Current Mailing Address Current Street Address _____________________________________ ___________________________________________ City State Zip City State Zip Phone: Office # ________________________ Mobile #____________________________________ ______________________________________ Name of Individual to Contact (if Registered Agent is a company) COUNTY OF ORANGE BHAMMERSLEY@ORANGECOUNTYNC.GOV PO BOX 8181 300 W. TRYON STREET HILLSBOROUGH, NC 27278 HILLSBOROUGH, NC 27278 919-245-2300 DocuSign Envelope ID: A6ECD43A-4359-4D26-A9B6-DA39647F9A40 (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. ______________________________________ 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. _____________________________________ _______________________________________ Type or print name Title or Authority _____________________________________ _______________________________________ Signature Date ------------------------------------------------------------------------------------------------------------------------------------ I, __________________________________, 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 that the above form was executed by him/her. Witness my hand and notarial seal, this ______day of _________________, 20_______ _______________________________________ Notary Seal My commission expires_____________________ BONNIE HAMMERSLEY COUNTY MANAGER DocuSign Envelope ID: A6ECD43A-4359-4D26-A9B6-DA39647F9A40 2/16/2023