NCC215852_FRO Submitted_20211021

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 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 Eagle Chase Subdivision - Lots 6, 8, 14, 15, 18, 19, 22 & 25
2. Location of land -disturbing activity: County Franklin City or Township Youngsville
I ilghway,Street Darius Pearce Rd (SR 1101) Latitude 35.951320 N Longitude 78.377455 W
3. Approximate date land -disturbing activity will commence; August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas);
3.46 AC
00
6. Amount of fee enclosed: $ 260.. 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 David Edwards E-mail Address [e-mail]
Telephone [phone] Cell # 919-696-1318 Fax # [phone]
9 Landowner(s) of Record (attach accompanied page to list additional owners).
Winslow Custom Homes, LLC 919-556-4700
Name
PO Box 610
Current Mailing Address
Youngsville NC
City State
10. Deed Book No. 2173
Telephone
140 East Main Street
Current Street Address
27596 Youngsville
Zip City
1804-1806
NC
State
919-556-4780
Fax Number
27596
Zip
Page No. 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):
Winslow Custom Homes, LLC [e-mail]
Name
PO BOX 610
11U11C1R IVld11111y. muuICJ.
Youngsville NC
City State
Telephone [phone]
E-mail Address
140 East Main Street
Current Street Address
27596 Youngsville NC
Zip City State
Fax Number n/a
27596
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
��� r L'
ype or pr"rit name Title orr►�Authorl y
S06to Date
a Notary Public of the County of
State of North Carolina, hereby certify that 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 L ( day of 20_
TERESA C SMITH qL_
PUBLIC Notary
OWKLIN COUNTY
STATE OF NORTH CAROLINA My commission expires