NCC215636_FRO Submitted_20211202

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 and/or fax
information unavailable, place N/A in the blank.)
Part A.
Brook Haven Subdivision
1. Project Name
2. Location of land -disturbing activity: County Franklin City or Township Dunn Township
Highway/Street Williams Road (SR 1733) Latitude 35.89450' N Longitude 782126V W
3. Approximate date land -disturbing activity will commence: October2021
4 Purpose of development (residential, commercial, industrial, institutional, etc ). Residential
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas). 3.95 AC
6. Amount of fee enclosed: $1'260 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
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 Moss E-mail Address [e-mail]
Telephone [phone] Cell # 919-556-3148 Fax # n/a
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Jason & Stephanie Hall n/a n/a
Name Telephone Fax Number
60 Happy Hen Lane Williams Road
Current Mailing Address Current Street Address
Louisburg NC 27549 Dunn Township NC 27882 n/a
City State Zip City State Zip
10. Deed Book No. 2206 Page No 1535 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.
Red Wells, LLC mike@cmppls com
Name
PO Box 610
Current Mailing Address
Youngsville NC 27596
City
State
E-mail Address
n/a
Current Street Address
Zip City State
Zip

Telephone [phone] Fax Number n/a
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 State Zip
Fax Number
(c) In 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:
FILM Engineering, Inc
[e-mail]
Engineering Firm or other consultant E-mail Address
Chase Massey, PE 919-402-8975
Individual contact person (type or print) Telephone
n/a
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.
Mike Moss
Type or print name
Member
Title or Authority
Sign ture Date
I, _ i xye(\ m . I'; n k.1e r _ , a Notary Public of the County of VG1 6
State of North Carolina, hereby certify that (,VVA k k • 'mass appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand., this dayt
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