HomeMy WebLinkAboutNCC223977_FRO Submitted_20221130FINANCIAL 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 Winchester Subdivision — Lots 1-10 & 17-32
2. Location of land -disturbing activity: County Hoke City or Township McLaughlin Township
Craftsman Ct, Hayloft Ct, Newcastle Ct &
Highway/Street Graystroke Lane Latitude(decimaidegrees) N 34.9726°Longitude(decimaidegrees) W-79.0562'
Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.11 Acres
6. Amount of fee enclosed: $ 1400,00 . 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 ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name Leslie Groves E-mail Address leslie roves hhhomes.com
Phone: Office # 486-4864 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DFC Revolver 11, LLC
Name Phone: Office #
1300 Sawgrass Village Cir., Bldg 5, Suite 24 Same
Current Mailing Address Current Street Address
Mobile #
Ponte Vedra Beach Fla 32082 Same
City State Zip City State Zip
Lots 3-10 & 19-32 Lots 3-10 & 19-32.
Deed Book No. 1445 Page No. 393 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).
H&H Constructors of Fayetteville LLC
Company Name
3709 Raeford Road, Suite 200
Current Mailing Address
lesliegrovesghhhomes. com
E-mail Address
Same
Current Street Address
Fayetteville NC 28304 Same
City State Zip City State Zip
Phone: Office # 910-486-4864 Mobile #
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
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is 2 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, of 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.
Leslie Groves
Tp.e or print name
1 �
Signature T
Division President
Title or Authority
10laS'1�
Date
616eet4 a Notary Public of the County of Lmlxvum
State of North Carolina, hereby certify that Le-61 i e— a vvvc5 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 -;�5- day of 20c-
0+++1r r 1 FI., � of ry
y commission expires -j5'1d — a L(
`,�N I AR
U�
r
4 � ND GO
�rrrri+►+��
Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
H&H Constructors of Fayetteville LLC 910-486-4864
Name Phone: Office # Mobile #
3709 Raeford Road Suite 200 Same
Current Mailing Address Current Street Address
Fayetteville NC 28304 Same
city State Zip City State Zip
Lots 1,2,17 & 18 Lots 1,2,17 & 18
Deed Book No. 1462 Page No. 374 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City
Deed Book No.
Landowner 4 of Record:
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.