NCC232743_FRO Submitted_20230913

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 Laurinburq Dollar General
2. Location of land-disturbing activity: County Scotland City or Township Laurinburq
Highway/Street Purcell Road Latitude 34.727656 Longitude 79.506642
3. Approximate date land-disturbing activity will commence: July 15, 2019
4. Purpose of development(residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.9 ac
6. Amount of fee enclosed: $ 130.00 , 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jody Bland E-mail Address jody( par5development.com
Telephone [phone] Cell# 910-512-8148 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Pegqie Gibson Jones, Demetra Kontos & Connie Dawes
Name Telephone Fax Number
11340 Lytch Dr.
Current Mailing Address Current Street Address
Laurinburg NC 28352
City State Zip City State Zip
10. Deed Book No. 4 Page No. 412 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):
Par 5 Development Group, LLC jody(@,,par5development.com
Name E-mail Address
2075 Juniper Lake Road
Current Mailing Address Current Street Address
West End NC 27376
City State Zip City State Zip

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.
-j sert- eU4iND 'It • sia r—
Type or print name Title or Authbrity
Sign a Date
Covht• tr.e
, a Notary Public of the County of Ma)
State of North Carolina, hereby certify that -0-05eph 14_ ' """mod appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 1
Witness my hand and notarial seal, this ( day of JLu' e.- , 20 1
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