NCC222943_FRO Submitted_20220816

FINANCIAL RESPONSIBILIThOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erasion 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.
1 . Project Name Lydia's Place Subdivision
2. Location of land-disturbing activity: County Davidson City or TownshipLexington
Highway/Street Byerly_Road _ Latitude 35-53. 25 N Longitude_ 80719-59 W
a Approximate date land-disturbing activity will commence:__ March , 2022 _ _
4. Purpose of development (residential , commercial , industrIal , institutional , etc . ) :_ Residential
5 . Total acreage disturbed or uncovered ( including off-site borrow and waste areas ) :_ 3 . 32 +/- acres
6 . Amount of fee enclosed : $ 400 .00 & SI . 000. 00 , The Express Permitting application fee is a dual charge .
The normal fee of $ 100 . 00 per acre ( rounded up to the next acre) is assessed without a ceiling
amount. In addition , the Express Permitting supplement is $250 . 00 per acre up to eight acres , after
which the Express Permitting supplemental fee is a fixed $2, 000 . 00 ( Example : 9 acres total is $2 ,900 ) .
7. Has an erosion and sediment control plan been filed? Yes _ No Enclosed x _
8 . Person to contact should erasion and sediment control issues arise during land-disturbing activity:
Name Justin Nifong E-mail Address Jmifongnkpatent1aw. com
Telephone [phone] Cell # Fax #
9 . Landowner(s ) of Record (attach accompanied page to list additional owners ) :
Riverfront Ventures , LLC 919-348-2194
Name Telephone Fax Number
3409 Union Grove Road 3409 Union Grove Road
Current Mailing Address Current Street Address
Winston-Salem NC 27127 Winston-Salem NC 27127
..
City State Zip City State Zip
10 . Deed Book No. 2527 Page No. _ 24$0 Provide a copy of the most current deed .
Part B .
1 . Company (les ) 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 pall)'.
• Riverfront Ventures , LLC Jmifongnkpatenllaw.com
Name E-mail Address
3409 Union Grove Road 3409 Union Grove Road
Current Mailing Address Current Street Address
Winston-Salem IBC 27127 Winston-Salem NC 27127
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
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
__ _
( c ) In order to facilitate Express Permitting , it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation :
Latham-Walters Engineering , Inc . mitchIwengineer. com
Engineering firm or other consultant E-mail Address
Mitchell S . Latham , PE 704-P895-8484
Individual contact person (type or print ) 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 .
Justin Nifong M
Q
Type . r print ame Title or Aut orityAdAdal _ 42. OZZ
m„tAi
Si naFure Date
I , eibm: tLSImpOit#11101111/'$64twy��� , a Notary Public of the County of °Gysi,iL
State of North Carolina , hereby certify that ��.},�„ � UIOfi _ appeared personally
before me this day and being duly sworn acknowledged that the abo e form was executed by him .
Witness my hand and notarial seal , this �i day of (Ling 202-2
DORIS CHARMAINE JACKSON111 A
O
NORY PUBLIC 0fry
Fchtk county
North Carolina My commission expires 3., 2-23
My Commission Expires March 141 2023 �