NCC223592_FRO Submitted_20221019

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
Project Name Middleton Subdivision Phase i
2. Location of land -disturbing activity: County Davidson City or Township Ty ro
Highway/Street Front Street Latltude(decimaldegrees) 35.7853 Longltude(decimaldegrees)-80.3348
Approximate date land -disturbing activity will commence:. September, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.9
6. Amount of fee enclosed: $ 1,100.00 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 M Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jim Merrill
Phone: Office #
E-mail Address merrill sa amorehomes.com
Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
RS Parker Homes, LLC
Name
502 Hickory Ridge Drive _
Current Mailing Address
Greensboro, NC 27409
City State Zip
843-780-1128
Phone: Office # Mobile #
502 Hickory Ridge Drive
Current Street Address
Greensboro, NC 27409
City State Zip
10. Deed Book No. DB 2452 Page No. 2061 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Saaamore Homes NC, Inc
Company Name
1348 Westgate Center Drive Suite 100
Current Mailing Address
Winston-Salem NC 27103
City State Zip
Phone: Office #
merrill cD..sagamorehomes.com
E-mail Address
1348 Westgate Center Drive, Suite 100
Current Street Address
Winston-Salem NC 27103
City State Zip
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:
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
Phone: Office #
City State Zip
Mobile #
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,
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.
Walton TrippBunker
Type or print name
Signature
Vice President
Title or Authority
94L-2o,2L
Date
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 Sqv� , 20
- VdLLabckl
Nota
Seal
My commission expires a
R A`/A����ii�i
Notary Public
Davie _
Count
Comm. Exp.
y� y i 0-03-2023
"'OF11111"00