NCC240227_FRO Submitted_20240126

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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. Project Name P73721.1 -Tap Root Subdivision System Connections
2. Location of land-disturbing activity: County Henderson City or Township Mills River
Jeffress Road 35°24'14.4"N 82°32'24.0"W
Highway/Street Latitude(decimal degrees) 35.404° LongitUde(decimal degrees) -82.540°
3. Approximate date land-disturbing activity will commence: February 12,2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): utility Linear
5. Total acreage disturbed or uncover ad (including off-site borrow and waste areas): 11.1 ac.
Express:$2,0uu
Regular:$1,200
6. Amount of fee enclosed Total:$ 3,200 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre(rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes E1 Enclosed EJ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bob Lepsic, PWS [e-mail]
E-mail Address
Phone: Office N/A Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Highway Division 14, District 1 N/A N/A
Name Phone: Office# Mobile#
4142 Haywood Road 4142 Haywood Road
Current Mailing Address Current Street Address
Mills River NC 287' Mills River NC 28742
City State Zip City State Zip
10. Deed Book No.NCDOT ROW Page No. NCDOT ROW 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 names)of the owner(s)may be fisted as the financially responsible party(ies).
Public Service Company of North Carolina, Incorporated [e-mail]
Company Name E-mail Address
P.O. Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28056-9486
City State Zip City State Zip
Phone: Office# 704 718 4114 Mobile# N/A
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:
CT Corporation System(NCSOS ID#0519077)
Attn:Sherry McGinnes(Project ID#0073721.1) [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office#302-777-0204 Mobile# N/A
Sherry McGinnes
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
N/A
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
S&ME, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Liane R.Morgan, P.E. 704-523-4726 N/A
Individual contact person (type or print) Phone: Office# Mobile#
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.
Andrew Moore, P.E. Director- Engineering&Construction
Typ or print name Title or Author'ty
97( )2111 2-02-3
Signature Date
tl
I, ►Cl I k- 14Vr r rt.do , a Notary Public of the County of &Q,c b i
State of North Carolina, hereby certify that I'yirek,) Nkboye, 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 Df L ��
1 r , 20 2 3
CYNTHIA M. ALVARADO
NOTARY PUBLIC Not
Gaston County
North Carolina
My Commission Expires iv., 11, ,,,... -(L
25 My commission expires QC . 4 t 202)

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:
Corn,Michael;Corn, Mary Louise Johnston;
Johnston,William F.;Johnston,Nancy Moore;
Johnston,Timothy N.
Name Phone: Office# Mobile#
735 Butler Bridge Rd 62 Valley View Road
Current Mailing Address Current Street Address
Fletcher NC 28732 Mills River NC 28759
City State Zip City State Zip
Deed Book No.776 Page No.60 Provide a copy of the most current deed.
Landowner 3 of Record:
Dillon,Shaun T.
Name Phone: Office# Mobile#
229 Pisgah Ridge Trail 0 No Address Assigned
Current Mailing Address Current Street Address
Mills River NC 28759
City State Zip City State Zip
Deed Book No.3736 Page No.79 Provide a copy of the most current deed.
Landowner 4 of Record:
Dillon,Shaun
Name Phone: Office# Mobile#
229 Pisgah Ridge Trl 229 Pisgah Ridge Trail
Current Mailing Address Current Street Address
Mills River NC 28759 Mills River NC 28759
City State Zip City State Zip
Deed Book No.3347 Page No. 1 Provide a copy of the most current deed.
Landowner 5 of Record:
The Farm at Mills River, LLC.
Name Phone: Office# Mobile#
1005 Cane Creek Road 0 No Address Assigned
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip
Deed Book No.3210 Page No.467 Provide a copy of the most current deed.

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 6 of Record:
Famiano,Anthony Trustee;Anthony Famiano Trust;Famiano,
Joanne TnustP'; ioann3 Famiano Trust
Name Phone: Office# Mobile#
197 Pisgah Ridge Trail
Current Mailing Address Current Street Address
Mills River NC 28759
City State Zip City State Zip
Deed Book No.3733 Page No.89 Provide a copy of the most current deed.
Landowner 7 of Record:
Brown, Elisabeth Joan, Brown, Brian Heath
Name Phone: Office# Mobile#
187 Pisgah Ridge Trail
Current Mailing Address Current Street Address
Mills River NC 28759
City State Zip City State Zip
Deed Book No.3842 Page No.43 Provide a copy of the most current deed.
Landowner 8 of Record:
Johnston,Matthew C.;Corn,Michael R;Corn, Mary Louise;Johnston,William
F.;Johnston,Nancy M;Johnston Timothy-M,Johnstrq, BradlpyA
Name Phone: Office# Mobile#
735 Butler bridge Road 0 No Address Assigned
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip
Deed Book No.3790 Page No. 389 Provide a copy of the most current deed.
PINS: 9642815743 19642910731 19642916934
Landowner 9 of Record:
D.R.Horton, Inc.
Name Phone: Office# Mobile#
7 Lagoon Road
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip
Deed Book No.3794 Page No. 678 Provide a copy of the most current deed.

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 10 of Record:
Vanwingerden International, Inc.
Name Phone: Office# Mobile#
4112 Haywood Road 1856 Jeffress Road
Current Mailing Address Current Street Address
Mills River NC 28759 Mills River NC 28759
City State Zip City State Zip
Deed Book No.507 Page No.453 Provide a copy of the most current deed.
Landowner 11 of Record:
Johnston,Timothy M.
Name Phone: Office# Mobile#
752 Butler Bridge Road 752 Butler Bridge Road
Current Mailing Address Current Street Address
Fletcher NC 28732 Fletcher NC 28732
City State Zip City State Zip
Deed Book No.1349 Page No.329 Provide a copy of the most current deed.
Landowner 12 of Record:
Mills River Partners
Name Phone: Office# Mobile#
4112 Haywood Road 0 No Address Assigned
Current Mailing Address Current Street Address
Mills River NC 28759
City State Zip City State Zip
Deed Book No. 1456 Page No. 580 Provide a copy of the most current deed.
Landowner 13 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.

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 14 of Record:
D.R.Horton,Inc.
Name Phone: Office# Mobile#
141 Tap Root Lane
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip City State Zip
Deed Book No.3794 Page No. 672 Provide a copy of the most current deed.
Landowner 15 of Record:
D.R.Horton, Inc.
Name Phone: Office# Mobile#
8001 Arrowridge Blvd 0 No Address Assigned
Current Mailing Address Current Street Address
Charlotte NC 28273
City State Zip City State Zip
Deed Book No.3998 Page No. 59 Provide a copy of the most current deed.
Landowner 16 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 17 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.