NCC222249_FRO Submitted_20220617

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 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 N/A in the blank.)
Part A.
1. Project Name Creekwood Farms — Lots 3, 7, 24, 36 and 39
2. Location of land -disturbing activity: County Cumberland City or Township Grays Creek
Highway/Street Creekwood Road Latitude 34.88573' Longitude-78.9215510
3. Approximate date land -disturbing activity will commence: December 03, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.72 acres
Amount of fee enclosed: $ 195.00 . 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).
Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Watson Caviness E-mail Address pj@,cavinessland.com
Telephone [phone] Cell # 910-237-0572 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Caviness Land Development, Inc. 910-339-6330 910-339-6333
Name Telephone Fax
1041 B Robeson St
Current Mailing Address
Fayetteville, NC 28305
City State Zip
1041 B Robeson St
Current Street Address
Fayetteville, NC 28305
City State Zip
10. Deed Book No. 10847 Page No. 431 Provide a copy of the most current deed.
Deed Book No. 11291 Page No. 842 ; Deed Book No. 11291 Page No. 862
Part B.
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):
Caviness Land Development, Inc. pjAcavinessland.com
Name E-mail Address
1041 B Robeson St 1041 B Robeson St
Current Mailing Address Current Street Address
Fayetteville, NC 28305 Fayetteville, NC 28305
City State Zip City State Zip
Telephone [phone] Fax Number 910-339-6333

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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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 «itli
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.
Watson G. Caviness
Type or print nam
Signature
President
Title or Authority
11 /22/2021
Date
I, Lori Simpson Epler , a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Watson G. Caviness 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 22nd day of November, 2021
Notary Public
Lori S'eaRSON Epler of
umTiab C liner, My commission expires 11 — 14 — 2024
North Carolina