NCC221920_FRO Submitted_20220523

DocuSign Envelope ID: E2C5AF87-E4BE-4D39-8502-200B16FF2CD7
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
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail andl
or fax information unavailable, place N/A in the blank.)
Part A. 1Project NameProperties, Wed LLC- MurrayRoad
. ___
2. Location of land -disturbing activity: County Forsyth City or Township
Highway/Street _Focus Ln Latitude 36.16977 Longitude-80.30258
3. Approximate date land -disturbing activity will commence: 5/25/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: S 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).
T. 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 Casey Jeter E-mail Address [e-mail]
Telephone Cell # 336-408-1146 _ Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WJH LLC
Name
3091 Governors Lake Dr, STE 300
Current Mailing Address
Norcross NC 30071
Telephone
Current Street Address
Fax Number
City State Zip City State Zip
10. Deed Book No. 74 Page No. 179 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.) It the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
_Dave Hodgman [e-mail]
Name E-mail Address
1225 Eastchester. Dr. 1225 Eastchester Dr.
Current Mailing Address Current Street Address
Highpoint NC 27265 Highpoint NC 27265
City State Zip City State Zip
Telephone [phone] Fax Number

DocuSign Envelope ID: E2C5AF87-E4BE-4D39-8502-200BiBFF2CD7
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
State Zip
E-mail Address
Current Street Address
City
Telep= one Fax Numbef
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:
Dave Hodgman [e-mail]
Name of Registered Agent E-mail Address
1225 Eastchester Dr. 1225 Eastchester Dr.
Current Mailing Address Current Street Address
Highpoint NC 27265 Highpoint NC 27265 _
City State Zip City State Zip
Telephone [phone] 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.
Dave Hodgman Regional President
Tvne.gr,pEot name Title or Authority
� C4 8/23/2021
igiia ure Date
Teddi Tate Carr a Notary Public of the County of Guilford
State of North Carolina, hereby certify that Dave Hodgman 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 23rd day of August
pecuSipned by v
TEDDI TATE CARR �1
Electronic Notary Public s -F.:a:--F=:•w
Guilford County Notary
Se �I North Carolina
ommission Expires 7/14/2023 My commission expires_
2021
7/14/2023