NCC223879_FRO Submitted_20221129

FINANCIAL RESPONSIBILITYIOWNERS HIP 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 NIA in the blank.)
Part A. NORTHEAST POINTE 11
1. Project Name
2. Location of land -disturbing activity: County Robeson City or Township Lumberton
Highway/Street Harrill Rd Latitude34.6245" Longitude-78.9759"
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Multi -Family Apts
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.00 AC.
6. Amount of fee enclosed: $ 600.00 . 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
Fred Mills Jr E-mail Address [e-mail]
Telephone [phone] Cell # NIA Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Michael and Barbara Walters
910-671-7493 NIA
Name
Telephone Fax Number
1887 Oakton Church Rd
1887 Oakton Church Rd
Current Mailing Address
Current Street Address
Fairmont NC 28340
Fairmont NC 28340
City State Zip
City State Zip
10. Deed Book No. 01827 Page No. 0878 Provide a copy of the most current deed.
Part B. Deed Book No. 01998 Page No.
0606
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.
NORTHEAST POINTE 11, LLC.
[e-mail]
Name
E-mail Address
PO Box 6171
5608 Spring Court, Suite 100
Current Mailing Address
Current Street Address
Raleigh NC 27628
Raleigh NC 27616
City State Zip
City State Zip
Teiephone 919.621.9186
Fax Number NIA

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:
N/A
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
Fred Mills, Jr
Type name
Signature
Manager
Title or Authority
Date
_C �,_ , a Notary Public of the County of WaKe
State of North Carolina, hereby certify that ri' ci (" , M )IZs le- 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
,JOSEPH R WARENDA
NOTARY PUBLIC
SeaIW� C�lNTY, NC
INy COMM* � 6-4•�3
q day of Ma tr-L 20 0 1
Nota
My commission expires [c� `�-'JDa-3