NCC231296_FRO Submitted_20230509

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 N/A in the blank.)
Part A.
1. Project Name Pine Bluff Road Subdivision
2. Location of land-disturbing activity: County Cabarrus/Stanly City or Township Locust
Highway/Street Pine Bluff Road Latitude 35° 15' 8.04" N Longitude 80° 27' 59.67" W
3. Approximate date land-disturbing activity will commence: April 01, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 48 acres
6. Amount of fee enclosed: $ 4,800.00 . 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).
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 Charles Worsham E-mail Address cworsham(c�smithdouglas.corn
Telephone Cell# [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
TPG/ZBJ Joint Ventures LLC/NC
Name Telephone Fax Number
C/O Taylor Properties LLC 6370 NC HWY 24/27 E
Current Mailing Address Current Street Address
Charlotte NC 28270 Charlotte NC 28270
City State Zip City State Zip
10. Deed Book No. 7092 Page No. 0029 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 or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
SDH Charlotte, LLC cworsham a(�smithdoualas.com
Name E-mail Address
PO Box 311 4297 NC HWY 24/27 E
Current Mailing Address Current Street Address
Midland NC 28107 Midland NC 28107
City State Zip City State Zip

Telephone f330)671-3271 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:
Matthew Chisholm for SDH Charlotte, LLC MChts l'ia(PA @—'5M- ittclo1i3 u'S • GisYv
Name of Registered Agent E-mail Address
PO Box 311 4297 NC HWY 24/27 E
Current Mailing Address Current Street Address
Midland NC 28107 Midland NC 28107
City State Zip City State Zip
Telephone 7o`i-30l— 132$ 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.
Charles sham Vice President Land Development
Type r. t na''/rr}yeeie Title or Authority
Signature Date
7
I, 5\931,16,71,t-e_ L CL Yrf,.(,( , a Notary Public of the County of 6 bQnrnfS
State of North Carolina, hereby certify that aarii.s ( -Shgyt4 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this 7 day of ntiOh , 20 �Z
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