NCC224114_FRO Submitted_20221213

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. Sorrell Oaks Subdivision
1. Project Name
2. Location of land -disturbing activity: County Franklin/Granville City or Township You ngsyiIle
Highway/Street SR 1147 (Holden Rd) Latitude 36.02780 Longitude-78.53740
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29
6. Amount of fee enclosed: $ 2900.00 . 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 Jeff Grote E-mail Address [e-mail]
Telephone [phone] cell # 919.971.5200 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sorrell Oaks Investments, LLC
919.971.5200
Name
Telephone Fax Number
7201 Creedmoor Rd, Ste 140
7201 Creedmoor Rd, Ste 140
Current Mailing Address
Current Street Address
Raleigh NC 27613
Raleigh NC 27613
City State Zip
City State Zip
10. Deed Book No. 2300 Page No. 2009-201 1 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.
Greenpointe L.L.C.
[e-mail]
Name
E-mail Address
7201 Creedmoor Rd, Ste 140
7201 Creedmoor Rd, Ste 140
Current Mailing Address
Current Street Address
Raleigh NC 27613
Raleigh NC 27613
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
.je (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:
Yem C✓U,-
Name of Regis Bred Agent
Current Mailing Address
�01 nA' Z-76 i 3
City State Zip
Telephone q) j q j, —SZCk)
i e(e aacg& 4e, Ac. Corn
-mail Ad ess
-7Z01 CYee� h air 11cQ c5� I
Current Street Address
AaNC_ Zi6►'�
City VState Zip
Fax Numbe
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.
Ty or rint n e Title or ut o ity
T`7�n A" 2 2,02Z
Signa D to
I, a Notary Public of the County of
"Jej—
State of North Carolina, hereby certify that appeared
personally before me this day and being duly jwdWrVacknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of �t/lC�i , 202a`
N O T N ; Notary
Seal �'Q� z -
My commission expires G 6
GBLIC
"'//�UiNTYNG\����\