NCC232197_FRO Submitted_20230808

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 Mason Ridge Subdivision.
2. Location of land-disturbing activity: County Harnett City or Township Barbecue
Highway/Street Nursery Rd. SR 1120 Latitude 35.27632 Longitude-78.98926
3. Approximate date land-disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):26.1 Ac
6. Amount of fee enclosed: $ 1,755. 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 X Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Elvis Faircloth E-mail Address ELVISFAIRCLOTHt7a YAHOO.COM
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Elvis & Stanley Faircloth
Name Telephone Fax Number
PO Box 1310
Current Mailing Address Current Street Address
Broadway, NC 27505
City State Zip City State Zip
10. Deed Book No. 3933 Page No. 378 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):
Elvis & Stanley Faircloth ELVISFAIRCLOTH(a�YAHOO.COM
Name E-mail Address
PO BOX 1310
Current Mailing Address Current Street Address
Broadway, NC 27505
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.
Elvis Fa'rcloth ( O er
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Signature Date
_41�3 I, O, d?a Notary Public of the County of Nekk
State of North Carolina, hereby certify that ! VI S C. t, r 03\--k- appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. c�
Witness my hand and notarial seal, this J day of S , 20 .2
a
Seal ��
My commission expires (.i _f `„)0 2 S'