NCC223568_FRO Submitted_20221017

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 Heritage Pointe- Lot 27
2. Location of land -disturbing activity: County Chatham City or Township New Hope
Highway/Street Heritage Drive Latitude 35.7411 Longitude-78.9711
3. Approximate date land -disturbing activity will commence: 12/01/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.12
6. 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).
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 Dipak Patel E-mail Address dipak5599(p)yahoo.com
Telephone [phone] Cell # 919-478-4759 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dipak Patel
Name Telephone Fax Number
1217 N Horner Blvd 1217 N Horner Blvd
Current Mailing Address Current Street Address
Sanford NC 27330 Sanford NC 27330
City State Zip City State Zip
10. Deed Book No. 01968 Page No. 0368, 0369 Provide a copy of the most current deed.
Part B.
1. 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):
Dipak Patel [e-mail]
Name
E-mail Address
1217 N Horner Blvd 1217 N Horner Blvd
Current Mailing Address Current Street Address
Sanford NC Sanford NC 27330
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
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.
Dipak Patel
Type or print na
Signature
Owner
Title or Authority
10/ 13/2022
Date
I, •��� � f - YW UL a Notary Public of the County of
State of North Carolina, hereby certify thatbl YJay.,.&,_Y)Rmm- OaW 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 day of 20 01
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