NCC241253_FRO Submitted_20240604

NC Department of
Environmental Quality
❑❑C
Received
Check if this project is ARK-cu 2J l 2 2213
Attach a copy of the Letter of Intuit towin Fun Salem
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Regional Office
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Ridgemont Subdivision Phase 3 & 4
'If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Davie City or Township Mocksville
Whitneyd 35.818721 -80.276879
Highway/Street J Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 9/14/21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 25
6. Amount of fee enclosed: $0.00 . 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 0 Enclosed El No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kurt Stawarz E-mail Address [e-mail]
Phone: Office# 336.517.2738 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WJH LLC a Delaware Limited liability company 336-517-2759
Name Phone: Office# Mobile#
3091 Governors Lake Drive Suite 300 3091 Governors Lake Drive Suite 300
Current Mailing Address Current Street Address
Norcross GA 30071 Norcross GA 30071
City State Zip City State Zip
10. Deed Book No. 01 2- ( C Page No. V'u�' 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).
WJH LLC [e-mail]
Company Name E-mail Address
3091 Governors Lake Drive Suite 300 3091 Governors Lake Drive Suite 300
Current Mailing Address Current Street Address
Norcross GA 30071 Norcross GA 30071
City State Zip City State Zip
Phone: Office# 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:
CT Corporation
Name of Registered Agent E-mail Address
160 Mine Lake Court 160 Mine Lake Court
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# Mobile#
Kurt Stawarz
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 instrument the Financially Responsible Party). I agree to provide
corrected information should the - .- - ' hange in the information provided herein.
Kurt Stawar Regional President
Type or print n.2.-!!��� Title or Authority
'//pai A I 0--) 12/14/23
I. ature Date
I, ...v 1 S • I.4-06,1, 1,f\c- , a Notary Public of the County of ,,.i,) 1. c(
State of North Carolina, hereby certify that 1Lui.1 S1-�we Y 2' 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`€ day of Dr C e vv )t� , 20 2 )
IRE U
NotaryLAU PuIblicS, North
HOGL CarNDolina N tary
Cilford County
My Commission Expires
January 06,2024 My commission expires i -C_ 2 -)7`j