NCC222911_FRO Submitted_20220815

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name The Pines at Pond Vallley
2. Location of land -disturbing activity: County Vance City or Township Henderson
Highway/Street US 158 Business 36.318917-78.508367
Latltude�decima� degrees) LOngliude�decuna� degrees)
3. Approximate date land -disturbing activity will commence: August, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 9.95 ac
6. Amount of fee enclosed 4,000.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad E. Abbott E-mail Address [e-mail]1
Phone: Office # 919-230-0996
Mobile #[phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Powell William H. Trustee
Name
244 Malone St.
Current Mailing Address
Houston, TX 77007
City State
10. Deed Book No. 559
Phone: Office #
244 Malone St.
Mobile #
Current Street Address
Houston, TX 77007
Zip City
Page No. 378
State
Zip
Provide a copy of the most current deed.

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).
Southbury Development, LLC [e-mail]
Company Name E-mail Address
20 Cochran Castle Circle 20 Cochran Castle Circle
Current Mailing Address Current Street Address
Pinehurst, NC 28374 Pinehurst, NC 28374
City State Zip City State Zip
Phone: office # 760-567-5039 Mobile # [phone]
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:
NA NA
Name of Registered Agent E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office # NA Mobile # NA
NA
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:
NA NA
Name of Registered Agent E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office # NA Mobile # NA
NA
Name of Individual to Contact (if Registered Agent is a company)
(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.
NA
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
C3 Design & Engineering, PLLC
Engineering firm or other consultant
Chad E. Abbott
Individual contact person (type or print)
[e-mail]
E-mail Address
919-230-0996 919-625-7368
Phone: Office #
Mobile #
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.
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Type rint name
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Signature
Title or thori y
& /�/a0d'
Date
1, �sco a Notary Public of the County of w4l/
State of North Carolina, hereby certify that-�-u�� `�(�� 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 11� day of Vli,Jl-Q 20c�)�
Rhonda O'Brien
NOTARY PUBLIC
Stanly County Notary
North Carolina
My C fission Expires June 7, 2027
My commission expires