NCC221420_FRO Submitted_20220414

RECEIVED
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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM FEB — 1 2022
SEDIMENTATION POLLUTION CONTROL ACT
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No person may initiate any land -disturbing activity on one or more acres as co4*4t*&i&4 Rwmai office
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 NIA in the blank.)
Part A. Nathan's Ridge
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Llllington
Highway/Street SR 1436 Latitude 35.4389 Longitude-78•8050
3, Approximate date land -disturbing activity will commence: 04-01-2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 33.2 acres
6. Amount of fee enclosed: $ 3,400.00 The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Phil Stephenson
[e-mail]
E-mail Address
Telephone cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KDP Development, 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. 3946 & 4105 Page No.428 & 426 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.
KDP Development, 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

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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.
Phil Stephenson Member Manager
nt name Title or Authority
2Z
ignature Date
I, a Notary Public of the County of L rl
State of North Carolina, hereby certify that _ �1 ► (?Y)60r) appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness m�taamd�Md notarial seal, this day of , 20
V •'�®BAR)-Notary
Seal oC)
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