NCC220705_FRO Submitted_20220209

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 NIA in the blank.)
Part A. Woodshire Subdivision Phase 7
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Llllington
Highway/Street Nursery Road Latitude 35.305067 Longitude 78.976044
3. Approximate date land -disturbing activity will commence: December 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 31.06 aC
6. Amount of fee enclosed: $ 2,080.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name PJ Gay E-mail Address [e-mail]
Telephone [phone] cell # 910-237-0572 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Woodshire Partners, LLC 910-481-0503
Name Telephone Fax Number
639 Executive Place - Ste. 400
Current Mailing Address Current Street Address
Fayetteville, NC 28305
City State Zip City State Zip
10. Deed Book No. 3446 Page No. 969 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 orfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Caviness Land Development, Inc [e-mail]
Name E-mail Address
639 Executive Place - Ste. 400
Current Mailing Address Current Street Address
Fayetteville, NC 28305
City State Zip City State Zip
Telephone [phone] 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.
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Li raa oo_ -, a Notary Public of the County of Cum 6o_y\ d
State of North Carolina, hereby certify that V .� . C appeared
personally before me this day and being duly sworn acknowledbed that the above form was
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