NCC221098_FRO Submitted_20220318

FINANCIAL RESPONSIBILiTYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Walter's Meadow
2. Location of land -disturbing activity: County Hoke City or Township Quewhiffle
Highway/Street N. Horace Walter Road Latitude 35-00'32" Longitude-79-21'21"
3. Approximate date land -disturbing activity will commence: Sept. 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.56 AC
6. Amount of fee enclosed: JQM 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 $685).
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:
9
Name Lee Humohrev E-mail Address Lee(Mdoubledewcom
Telephone [phone] Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Walter's Meadow, LLC [phone]
Name Telephone Fax Number
2919 Breezewood Ave. Suite 100 Same
Current Mailing Address Current Street Address
Fayetteville NC 28303 Same
City State Zip City
10. Deed Book No. DB 262, PG 105, DB 262, PG 108, DB 504, PG 406
current deed.
State
Zip
Provide a copy of the most
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):
Walter's Meadow LLC DrHuff(@HuffFamilyOffice.com
Name E-mail Address
2919 Breezewood Ave Suite 100
Current Mailing Address
Fayetteville NC 28303
City State Zip
Telephone [phone]
2919 Breezewood Ave. Suite 400
Current Street Address
City State Zip
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 State ,Zip
Telephone
E-mail Address
Current Street Address
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.
i
Signature
mannow-
Title or Author'
0ckdaer It, aoa 1
Date
ArMO^ "\ , a Notary Public of the County of Cul-bptrIa^d
State of North Carolina, hereby certify that Y< a.l An Hu 0' appeared
personally before me this day and being d ly sworn Tacknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a(.j day of 0C. Vo ,- , 20 c) �
•
tar
My commission expiresa