NCC240436_FRO Submitted_20240215

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 Appleton South Lots 3 and 32
2. Location of land-disturbing activity: County Cumberland City or Township Carvers Creek Township
Highway/Street Cresswell Moor Way Latitude(decimai degrees)35.142563 Longitude(decimai degrees)-78.896407
3. Approximate date land-disturbing activity will commence: February 02, 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.64 acres
6. Amount of fee enclosed $100.00 + $250.00. 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 X No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Watson Caviness E-mail Address pi( .cavinessland.com
Phone: Office# 910-339-6330 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caviness Land Development, Inc. 910-339-6330 910-237-0572
Name Phone: Office# Mobile#
175 Tennessee Walker Dr 175 Tennessee Walker Dr
Current Mailing Address Current Street Address
Fayetteville NC 28376 Fayetteville NC 28376
City State Zip City State Zip
10. Deed Book No. 11896 Page No. 679 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).
Caviness Land Development, Inc. pi(@,cavinessland.com
Company Name E-mail Address
175 Tennessee Walker Dr 175 Tennessee Walker Dr
Current Mailing Address Current Street Address
Fayetteville NC 28376 Fayetteville NC 28376
City State Zip City State Zip
Phone: Office# 910-339-6330 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:
Caviness Land Development, Inc. picavinessland.com
Name of Registered Agent E-mail Address
175 Tennessee Walker Dr 175 Tennessee Walker Dr
Current Mailing Address Current Street Address
Fayetteville NC 28376 Fayetteville NC 28376
City State Zip City State Zip
Phone: Office# 910-339-6330 Mobile# [phone]
Watson G. Caviness
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 City State Zip
Phone: Office# 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
(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:
Larry King and Associates, RLS, PA larrv(c�lkanda.com
Engineering firm or other consultant E-mail Address
Larry King 910-483-4300 910-483-4300
Individual contact person (type or print) 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.
Watson Caviness President
Type or print nam Title or Authority
01/29/2024
Signature Date
I, Lori Simpson Epler , a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Watson Caviness 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 29th day of January , 2024
C3W1-14(1)11-f24. °/?U 412-Q-e-k)
/�yi Notary Public L1 Notary
Lori Srripsan Epler
Se utunbarianl. County My commission expires 11/14/2024
1 North Carolina raj; •