NCC220690_FRO Submitted_20220209

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
annrnnriate Regional Office. (Please tine nr nrint and if the - lestion is not applicable or the e-mail and!
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or fax information unavailable, place N/A in the blank.) v
Part A. 1. Project Name Brookstone Village
2. Location of land -disturbing activity: County Hoke City or Township MCLauchlln
Highway/Street US 401 Latitude 35.025328 Longitude 79.145642
3. Approximate date land -disturbing activity will commence: December 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 42.1 ac
6. Amount of fee enclosed: $2,795 . 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 Chris Cates E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
John Anderson Williams, Jr., et al. (see attached)
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. 722 Page No. 292 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.
Creekstone Meadows, LLC [e-mail]
Name
639 Executive Place - Suite 400
Current Mailing Address
Fayetteville, NC 28305
C ity
State Zip
E-mail Address
Current Street Address
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
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
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.
or
Signature
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Title or Authority
glal a �
Date
I, AynsA U 0-c f"-)CLr' , a Notary Public of the County of CUrn1ne.0 lQnd
State of North Carolina, hereby certify that -D. RQ1 ph HLAN qm appeared
personally before me this day and being duly sworn a nowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of Sep}2mlocr' 20 oft
Seal
Not
My commission expires