NCC222458_FRO Submitted_20220708

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 and/or fax
information unavailable, place N/A in the blank.)
Part A.
Project Name Collier Gate Estates Subdivision
Location of land -disturbing activity: County Cumberland City or Township Carvers Creek
Highway/Street W Reeves Bridge Rd Latitude 35.257753 Longitude= 78.823125
3. Approximate date land -disturbing activity will commence: April 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residen'Lial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.0 ac
6. Amount of fee enclosed: $ 1.300 The application fee of $100.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: a 8.10-acre application fee is $900).
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 Ben Stout
Telephone [phone] Cell #
E-mail Address ben6a benstoutconstruction.com
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AGS Land, LLC 910-779-0019
Name Telephone
1786 Metromedical Drive
Current Mailing Address
Fayetteville NC 28304
City State Zip
10. Deed Book No. 11340 Page No. 523
Part B.
Current Street Address
City
State
Fax Number
Zip
Provide a copy of the most current deed.
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.
Stout Land Development, LLC
Name
1786 Metromedical Drive
Current Mailing Address
Fayetteville NC 28304
City State Zip
ben(a)benstoutconstruction. com
E-mail Address
Current Street Address
City State Zip

Telephone [phone]
Fax Number
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.
Type or ' t n me
Od
Signature
�'6c
Title or Authority
Date
2 S ) `A —P2.2
%(.V r4 a Notary Public of the County of
State of North Carolina, hereby certify that \�en appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my harp end notarial seal,
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this 2s day of S4nUcfy 20 25
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Notary
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