NCC230780_FRO Submitted_20230322

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 Geotion, 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 oddnsoo or phone
number ieunavailable, place N/A inthe b/mnk.)
Part A.
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1. Project Name Magnolia Mallory Creek
��[U��VV'[�� Leland
2. Locat�nofkand-d�tudbingo���y: CountBrunswick '~ C�yorTnwnohi
K8@UOp/ (�[��� l�F 34.18 -78O1
Highway/Street '' Creek ~ Latitudememma/�oo�oa�°�_ Long�ud�(ue�/ma/ueoemoL'.^^^,`_
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3. Approximate date land -disturbing activity will commence: ~�' receipt ' approval
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4. Purpose of development (res�enUa|, commercial, industrial, institutional, ebj� Residential
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6. Total acreage d��rbedoruncovered (including off-m�eborrow and waste ereae:'-'1�'`-"-
S. Amount offee enclosed: The application fee of$1OO.00per acre (rounded
uptothe next acre) iaassessed without aceiling amount (Exampka:8.1O-aonaapplication fee iaS9OO).
Checks should baaddressed boNCDEC>.
7. Has anerosion and sediment control plan been filed? Yes Enclosed Mx No []
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
[�C3OB|� ���pD [e-mail]
Name Donald E-mail Address ~^ ^^~ »��^~''' '^~ -
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Phone: Office K8obi|e# ~'� ~~^~ ~- ''
Q. Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton, Inc. 910-515-9561
- - - -- -Ne/ne Phone: -Office # -'- - -- -MobUe#-
6752 Parker Farm []C,Suite 21D 6752 Parker Farm Fl[/Suite 210
Current Mailing Address
Wilmington NC 28405
City State
Current Street Address
\8/|m'nnfn[l NC 27405
Zip City
State
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10. Deed Book No -`^'"^' Page No. =°^^ Provide acopy ofthe 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 names) of the owner(s) may be listed as the financially responsible party(ies).
D.R. Horton, Inc. [e-mail]
Company Name E-mail Address
6752 Parker Farm Dr., Suite 210 6752 Parker Farm Dr., Suite 210
Current Mailing Address
Wilmington NC
City State
Phone: Office #
ME
Current Street Address
Wilmington NC 28405
Zip City State
Mobile# [phone]
Zip
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:
Elizabeth Shelton
Name of Registered Agent
6752 Parker Farm Dr., Suite 210
Current Mailing Address
Wilmington NC 28405
City
[e-mail]
E-mail Address
6752 Parker Farm Dr., Suite 210
Current Street Address
Wilmington NC 28405
State Zip City
Phone: Office # Mobile# [phone]
State Zip
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.
Donald Aiken Assistant Secretary
Type or
Title or Authority
// Lod fed
Date
1, I Khi EL, A;, I,) r- /? `l , a Notary Public of the County of ftj (4t/ou
State of North Carolina, hereby certify that �bA)q t .l) A-IQ-Ek) 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 ) day of 1�%WAZ,�j , 20 -2'3
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.��```�� F�1V��''•. Notary
XAoTaRY My commission expires DS1r7l.,?o.05
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