NCC215957_FRO Submitted_20211103

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 Lane Farms
2. Location of land -disturbing activity: County Harnett
3
Highway/StreetSR 1407 Latitude 35.5565
City or Township Buckhorn
Approximate date land -disturbing activity will commence: 09/01/2021
Longitude -78.8948
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.8 acres
6. Amount of fee enclosed: $ 195.00 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Phil Stephenson
E-mail Address [e-mail]
Telephone [phone] Cell # 919-427-8654 Fax #
9. Landowner(s) of Record (attach accompanied
page to list additional owners):
Southern Living Investment Properties, LLC
919-427-8654
Name
Telephone Fax Number
1187 N. Raleigh St.
1187 N. Raleigh St.
Current Mailing Address
Current Street Address
Angier NC 27501
Angier NC 27501
City State Zip
City State Zip
10. Deed Book No. 3938 Page No.
226 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):
Southern Living Investment Properties, LLC
[e-mail]
Name
E-mail Address
1187 N. Raleigh St.
1187 N. Raleigh St
Current Mailing Address
Current Street Address
Angier NC 27501
Angier NC 27501
City State Zip
City State Zip
Telephone [phone]
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Phil Stephenson Member Manager
Type or print name
Signature
Title or Authority
9 Z 3' Z/
Date
1, (�'. r' a Notary Public of the County of LkMn,s3kn
State of North Carolina, hereby certify that T) ', � ak:L a,zw 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 Pr day of 20 r
JAMIE HOLLAND _
Notary_ Public, North Carolina
CffiliNo
����tt ssioCounnExpires ty
3 My
December 14, 2021 My commission expires �(