NCC224161_FRO Submitted_20221222

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1.
2.
3.
4.
Project Name.
Magnolia Hills Subdivision
Location of land -disturbing activity: County Harnett City or Township Cameron
S R 1323 35.317722-79.120406
Highway/Street Latltude(decimai degrees) Longitude(decimal degrees)
Approximate date land -disturbing activity will commence: June 15, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.3
6. Amount of fee enclosed: $ 2,400.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
9
Name Shaun Gardner
Phone: Office # 910-988-8172
E-mail Address [e-mail]
Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Galt Land Development, LLC 910-988-8172
Name
206 Shoreline Drive
910-988-8172
Phone: Office # Mobile #
206 Shoreline Drive
Current Mailing Address Current Street Address
Raeford NC 28376 Raeford NC 28376
City State Zip City
10, Deed Book No. 3955 Page No. 716
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Galt Land Development, LLC
Company Name
206 Shoreline Dr.
Current Mailing Address
Raeford NC 28376
City State
Phone: Office # 910-988-8172
[e-mail]
E-mail Address
206 Shoreline Dr.
Current Street Address
Raeford NC 28376
Zip City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation,
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Shaun Gardner
Type or print name ,
Signature
Manager
Title or Authority
'f (� t
Date
i, ,V1 o 1 i a r , a Notary Public of the County of H 0 IL
State of North Carolina, hereby certify that Awn YL2 r appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1 `r day of k 1-11 , 20�
0? ��.. ••••1 Notary
WNW,My commission expires
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•,'�y�kS COV�y���
►►

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Galt Land Development, LLC
910-988-8172 910-988-8172
Name
Phone: Office # Mobile #
206 Shoreline Drive
206 Shoreline Drive
Current Mailing Address
Current Street Address
Raeford NC
28376
Raeford NC 28376
City State
Zip
City State Zip
Deed Book No. 3889
Page No. 243 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.