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Check if this project is ARPA-funded ☐ <br /> <br />FINANCIAL RESPONSIBILITY/OWNERSHIP FORM <br />SEDIMENTATION POLLUTION CONTROL ACT <br /> <br />No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any <br />activity under a common plan of development of this size as covered by the NCG01 permit, before this form <br />and an acceptable erosion and sedimentation control plan have been completed and approved by the Land <br />Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate <br />Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone <br />number is unavailable, place N/A in the blank.) <br /> Part A. <br /> <br />1. Project Name_______________________________________________________________________ <br /> <br />*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below <br />under which you applied for funding through the Division of Water Infrastructure (DWI). <br /> <br />_____________________________________________________________________________ <br /> <br />2. Location of land-disturbing activity: County_________________City or Township_________________ <br /> <br />Highway/Street____________________ Latitude(decimal degrees)________ Longitude(decimal degrees)________ <br /> <br /> 3. Approximate date land-disturbing activity will commence:_____________________________________ <br /> <br /> 4. Purpose of development (residential, commercial, industrial, institutional, etc.):____________________ <br /> <br /> 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_________________ <br /> <br />6. Amount of fee enclosed: $____________________. The application fee of $100.00 per acre (rounded <br />up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900). <br />Checks should be addressed to NCDEQ. <br /> <br /> 7. Has an erosion and sediment control plan been filed? Yes ☐ Enclosed ☐ No ☐ <br /> <br /> 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: <br /> <br /> Name________________________________ E-mail Address_______________________________ <br /> <br />Phone: Office # ________________________ Mobile # ____________________________________ <br /> <br /> 9. Landowner(s) of Record (attach accompanied page to list additional owners): <br /> <br /> ____________________________________ ________________________ _________________ <br />Name Phone: Office # Mobile # <br /> <br />____________________________________ ___________________________________________ <br />Current Mailing Address Current Street Address <br /> <br /> ____________________________________ ___________________________________________ <br /> City State Zip City State Zip <br /> <br />10. Deed Book No._______________ Page No.______________ Provide a copy of the most current deed. <br /> <br /> <br /> <br /> <br />GRAVELLY HILL MIDDLE SCHOOL STORMWATER WETLAND RETROFIT <br />ORANGE CHEEKS <br />WEST TEN ROAD 36.07067 79.19992 <br />6/1/2023 <br />SCM <br />1.8 <br />200 <br />CHRISTOPHER SANDT CSANDT@ORANGECOUNTYNC.GOV <br />919-245-2583 512-590-0359 <br />COUNTY OF ORANGE 919-245-2583 512-590-0359 <br />PO BOX 8181 131 W. MARGARET LAN <br />HILLSBOROUGH, NC 27278 HILLSBOROUGH, NC 27278 <br />4014 24-26 <br />DocuSign Envelope ID: A6ECD43A-4359-4D26-A9B6-DA39647F9A40