NCC222865_FRO Submitted_20220810

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. The Lakes Golf Course Clubhouse
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Boiling Spring Lakes
Highway/Street 591 S. Shore Dr Latitude 34D01'54" Longitude 78D03'06"
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .86
6. Amount of fee enclosed: $ (previously paid) 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 Roger Dutton E-mail Address [e-mail]
Telephone Cell # 409-200-1766 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DHLN Holdings, LLC 409-200-1766
Name Telephone Fax Number
59 Fairway Drive
Current Mailing Address Current Street Address
Southport NC 28461
City State Zip City State Zip
10. Deed Book No. 4724 Page No. 335 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.
DHLN Holdings, LLC [e-mail]
Name E-mail Address
59 Fairway Drive Same
Current Mailing Address Current Street Address
Southport NC 28461
City State Zip 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
Murrent Mailing Address Current Street Address
city
state zip city
Telephone Pax Number
Mete Zip
(b) if the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of tho 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 Mate Alp DO Mate zip
Telephone Fax Number
The above information is true and correct to the beat of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if on 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.
R®o®r C. Dutton President, DHLN Holdinn LL
Type or print name Title or Authority
"7a �
signature ®at®
1, C►�i nz &a� , a Notary Public of the County of t sd
Mate of North Carolina, hereby certify that Y� o _ appeared
personally before me this day and being duly worn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this -I-day of Art
ERINN PITTENGER
NOTARY PUBUC Notary
�e I BRUNSWICK COUNTY, NC
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