NCC215801_FRO Submitted_20211019

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 Y Court ards at Chestnut
2. Location of land -disturbing activity: CountyUnion City or Township Stallings
Highway/Street0 Chestnut Lane Latitude35.0647 Longitude80•7133
3. Approximate date land -disturbing activity will commence: September 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.32 ac
6. Amount of fee enclosed: $ 650.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Mike Davis E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Epcon Chestnut, LLC
Name Telephone Fax Number
11020 David Taylor Dr, STE 105
Current Mailing Address
Charlotte, NC 28262
City State
10. Deed Book No. 07628
Current Street Address
Zip City
Page No. 0546
State
up
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.
Epcon Chestnut, LLC [e-mail]
Name
11020 David Taylor Dr, STE 105
Current Mailing Address
Charlotte, NC 28262
City
State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State
Fax Number
Zip

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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue
Current Mailing Address Current Street Address
Raleigh NC 27608
City State Zip City State Zip
Telephone [phone] 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 th#re be any change in the information provided herein.
Bob Kardos Regional President
Type or krkit,name
Title or Authority
� A 110
Date
I, e cCj1 , a Notary Public of the County of
State of North Carolina, hereby certify that_e)ck) S� �`" 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 day of('''�C��� , 20L—
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