NCC221796_FRO Submitted_20220518

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the
Henderson County. Submit this form to: 240 Second Avenue East, Hendersonville, NC 28792. (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.
1. Project Name Heritage Park
2. Location of land -disturbing activity: County Henderson City or Township Fletcher
Highway/Street 82 Rutledge Road Latitude 35.4392 Longitude-82.5182
3. Approximate date land -disturbing activity will commence: 02/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18.70 AC
6. Amount of fee enclosed: $ 5.900 The application fee of $300.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 7.2-acre application fee is $300.00
x 8 = $2400.00 plus $200.00 plan review fee = $2600.00).
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 Ken Jackson E-mail Address Kenjacksonglb'andco.com
Telephone [phone] Cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Richard Eugene Lance (see attached) N/A NIA
Name Telephone Fax Number
82 Rutledge Road 82 Rutledge Road
Current Mailing Address Current Street Address
Fletcher NC 28732 Fletcher NC 28732
City State Zip City State Zip
10. Deed Book No. 3146:3146:1251 Page No. 236: 2W 40 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.
Jackson Family Developers, LLC [e-mail]
Name E-mail Address
PO Box 1157 N/A
Current Mailing Address
Arden NC 28704
City State Zip
Telephone [phone]
Current Street Address
N/A N/A N/A
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:
N/A
Name
N/A
Current Mailing Address
N/A N/A N/A
City State Zip
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A NIA N/A
City
Fax Number N/A
State Zip
(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:
Kevin G. Jackson
Name of Registered Agent
3 Walden Ridge Drive Suite 300
Current Mailing Address
Asheville NC 28803
City State Zip
Telephone N/A
N/A
E-mail Address
3 Walden Ridge Drive Suite 300
Current Street Address
Asheville NC 28803
City
Fax Number N/A
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.
Type or print name
Signature
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Title or Authority
Date
e S� T1y R L,d kc—a Notary Public of the County of
State of North Carolina, hereby certify that K -Ll t A% G tRAVt Z_ftc_ j',SQA appeared --
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this C_day o r1 20 a �_
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