NCC216136_FRO Submitted_20211104

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. BrantleyPlacePh1 - Clearing
1. Project Name Phase earg
2. Location of land -disturbing activity: County Lee City or Township West Sanford
Highway/Street Pioneer Dr Latitude35.4429 Longitude-79.2107
3. Approximate date land -disturbing activity will commence: April 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.1
6. Amount of fee enclosed: $1 ,755 . 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 x Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Van Groce E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Shirley & Jimmy Wall
919-499-8845
Name
Telephone Fax Number
2332 Jefferson Davis Hwy
Current Mailing Address
Current Street Address
Sanford, NC 27330
City State Zip
City State Zip
10. Deed Book No. 1066/885 Page No. 1379/227 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.
Copper Ridge Development, LLC
[e-mail]
Name
E-mail Address
PO Box 2825
1504 S. Horner Blvd
Current Mailing Address
Current Street Address
Sanford, NC 27331
Sanford, NC 27330
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
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.
Van Groce
Type or print name
Signature
member/manage
Title or Authority
2/17/21
Date
Sandra Trogdon , a Notary Public of the County of Lee
State of North Carolina, hereby certify that Van Groce
personally before me this day and being duly sworn
executed by him.
Witness my hand and ngWria ,seW this
Sr.4 ODyy'.
AR
CO
Seal. PU8 \G
sy •��
F COVea�,
appeared
acknowledged that the above form was
17 day of February 12021
No a
My commission expires 3/15/25

February 18, 2021
NC DENR, LQS
Attn: Sally Castle
3800 Barrett Drive
Raleigh, NC 27609
I, Shirley & Jimmy Wall owners of Parcels 9631-86-5489-00, 9631-76-
5126-00, 9631-75-6958-00, 9631-76-4207-00, 9631-76-3324-00,
9631-76-1056-00, 9631-76-2073-00 & 9631-75-4929-00, recorded in
Deed Book 782, Page 314 and Deed Book 1379, Page 227 give
consent to Copper Ridge Development LLC (Mr. Van Groce), for filing
an erosion control plan and to conduct the anticipated land disturbing
activity.
Copper Ridge Development, LLC will be the responsible party for any
land disturbance activities on this property.
Sincerely,
Shirley & Jimmy Wall
2332 Jefferson Davis Hwy
Sanford, NC 27330