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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM <br /> SEDIMENTATION POLLUTION CONTROL ACT <br /> No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this <br /> form and an acceptable erosion and sedimentation control plan have been completed and approved by the <br /> Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if <br /> the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.) <br /> Part A. <br /> 1. Project Name_Hillsborough Area EDD Phase 1 Water and Sewer Extensions <br /> 2. Location of land-disturbing activity: County_Orange City or Township_Hillsborough <br /> Highway/Street_1-40 & Old Hwy 86 _Latitude_360 2' 16.92" N Longitude_7906'5.58"W _ <br /> 3. Approximate date land-disturbing activity will commence:_October 2018 <br /> 4. Purpose of development(residential, commercial, industrial, institutional, etc.):.Extend water&sewer infrastructure <br /> 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.29 acres <br /> 6. Amount of fee enclosed: $—$520 . The application fee of$65.00 per acre (rounded <br /> up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585). <br /> 7. Has an erosion and sediment control plan been filed? Yes_X No Enclosed <br /> 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: <br /> Name.Christoper J. Sandt, P.E., Staff Engineer E-mail Address_csandt @orangecountync.gov <br /> Telephone_(919)245-2583 Cell#_(919) 590-0359 Fax# <br /> 9. Landowner(s) of Record (attach accompanied page to list additional owners): <br /> See attached page <br /> Name Telephone Fax Number <br /> Current Mailing Address Current Street Address <br /> City State Zip City State Zip <br /> 10. Deed Book No. Page No. Provide a copy of the most current deed. <br /> Part B. <br /> 1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a <br /> comprehensive list of all responsible parties on an attached sheet): <br /> Bonnie Hammersley bhammersley @orangecountync.gov <br /> Name E-mail Address <br /> P.O. Box 8181 200 South Cameron Street <br /> Current Mailing Address Current Street Address <br /> Hillsborough NC 27278 Hillsborough NC 27278 <br /> City State Zip City State Zip <br /> Telephone.(919)245-2306 Fax Number,(919)644-3004 <br />