NCC232934_FRO Submitted_20230928

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
GENERAL RESIDENTIAL LOT DEVELOPMENT PLAN APPLICATION
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 Environment and Natural Resources. (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 Redah Acres
2. Location of land-disturbing activity: County Stanley City or Township Locust
Highway/Street Church St Subdivision Name Redah Acres
3. Approximate date land-disturbing activity will commence: 12-15-2021
4. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3
5. Amount of fee enclosed: $ 300 (payable to NCDENR). The application fee of
$65.00 per acre (rounded up to the next acre) is assessed. For General Residential Lot Development
Plans, total acreage disturbed is limited to 5 acres (Example: a 2.3-acre application fee is $195.00).
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ryan Mcgee E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
MHC at Locust LLC 704-400-5321
Name Telephone Fax Number
4608 Carriker Rd 4608 Carriker Rd
Current Mailing Address Current Street Address
Monroe NC 28110 Monroe NC 28110
City State Zip City State Zip
8. Deed Book No.28 Page No.297(1) Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
MHC at Locust LLC. [e-mail]
Name E-mail Address
4608 Carriker Rd 4608 Carriker Rd
Current Mailing Address Current Street Address
Monroe NC 28110 Monroe NC 28110
City State Zip City State Zip
Telephone [phone] Fax Number
(If the landowner and financially responsible party are not the same, a landowner-builder agreement is required)

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:
Michael Ryan McGee [e-mail]
Name of Registered Agent E-mail Address
4608 Carriker Rd 4608 Carriker Rd
Current Mailing Address Current Street Address
Monroe NC 28110 Monroe NC 28110
City State Zip City State Zip
Telephone [phone] Fax Number
The information on this form 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.
Ryan Mcgee Manager
Type or print name Title or Authority
9-2 7— 23
Signs Date
I, /1-2..1 , a Notary Public of the County of I LJ UDA..
State of North Carolina, hereby certify that A40 � appeared
personally before me this day and being dRLcu
sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 017 day oc airl , 20 a3
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