NCC241899_FRO Submitted_20240710

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 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 Wastewater Facilities, Contract 18.0— Lower Dutchman's Creek Sewer
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Gaston City or Township Mount Holly
Highway/Street Lanier Drive Extension Latitude(decimal degrees)35.318431 Longitude(decimal degrees)-81.024980
3. Approximate date land-disturbing activity will commence: November 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.0 Acres
6. Amount of fee enclosed: $800.00 . 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 ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jonathan Wilson, MPM E-mail Address [e-mail]
Phone: Office#704.827.3931 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners): See Attached
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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).
City of Mount Holly [e-mail]
Name E-mail Address
Post Office Box 406 400 East Central Avenue
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Phone: Office# 704.827.3931 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:
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)
(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.
Danny Jackson City Manager
Ty r print nam Title or Authority
" (At 41,11 —7-1) 21
Signature (, Date
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I, 4r}'1 /�J'R. A�"I f/11 Pk , a Notary Public of the County of 5
State of North Carolina, hereby certify that 1111( :LC�Sw appeared personally
before me this day and being duly sworn acknowledge J..that the above form was executed by him/her.
Witness,my hand and notarial seal, this (Z day of �Lv►._2 , 20ota
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My commission expires � _ -b -e—
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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 1 of Record:
City of Mount Holly N/A N/A
Name Phone: Office# Mobile#
Post Office Box 406 _ West Nims Avenue
Current Mailing Address Current Street Address
Mount Holly_ NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4976 Page No. 684 Provide a copy of the most current deed.
Landowner 2 of Record:
Runnymeade Homeowner's Association Inc. N/A N/A
Name Phone: Office# Mobile#
Post Office Box 158 West Walnut Avenue
Current Mailing Address Current Street Address
Gastonia NC 28053 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 3005 Page No. 341 Provide a copy of the most current deed.
Landowner 3 of Record:
Runnymeade Homeowner's Association Inc. N/A N/A
Name Phone: Office# Mobile#
Post Office Box 158 Lantana Drive
Current Mailing Address Current Street Address
Gastonia NC 28053 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 3005 Page No. 341 Provide a copy of the most current deed.
Landowner 4 of Record:
LLB Enterprises LLC N/A N/A
Name Phone: Office# Mobile#
Post Office Box 706 Woodlawn Avenue
Current Mailing Address Current Street Address
Denver NC 28037 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4629 _ Page No. 671 _ Provide a copy of the most current deed.

Landowner 5 of Record:
Akilah Ross Ensley N/A N/A
Name Phone: Office# Mobile#
3002 Ellsworth Drive South Woodcliff Lane
Current Mailing Address Current Street Address
Greenville SC 27834 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4548 Page No. 1553 Provide a copy of the most current deed.
Landowner 6 of Record:
Clyde A. & Delphine K. Graham N/A _ N/A
Name Phone: Office# Mobile#
2046 Leslie Drive South Woodcliff Lane
Current Mailing Address Current Street Address
Gastonia NC 28054 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 652 Page No. 185 Provide a copy of the most current deed.
Landowner 7 of Record:
Akilah Ross Ensley N/A N/A
Name Phone: Office# Mobile#
3002 Ellsworth Drive South Woodcliff Lane
Current Mailing Address Current Street Address
Greenville SC 27834 Mount Holly NC 28120
City State Zip
Deed Book No. 4548 Page No. 1553 Provide a copy of the most current deed.
Landowner 8 of Record:
Runnymeade Homeowner's Association Inc. N/A N/A
Name Phone: Office# Mobile#
Post Office Box 158 _ South Woodcliff Lane
Current Mailing Address Current Street Address
Gastonia NC 28053 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 3005 Page No. 341 Provide a copy of the most current deed.

Landowner 9 of Record:
Joseph D. & Misty S. Griffin N/A N/A
Name Phone: Office# Mobile#
145 Lantana Drive 145 Lantana Drive
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 3309 Page No. 449 _ Provide a copy of the most current deed.
Landowner 10 of Record:
SFR JV-1 2020-1 Borrower LLC N/A N/A
Name Phone: Office# Mobile#
1508 Brookhollow Drive 149 Lantana Drive
Current Mailing Address Current Street Address
Santa Ana CA 92705 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 5284 _ Page No. 2199 Provide a copy of the most current deed.
Landowner 11 of Record:
Susan L. Taliaferro N/A N/A
Name Phone: Office# Mobile#
153 Lantana Drive 153 Lantana Drive
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4410 Page No. 72 Provide a copy of the most current deed.
Landowner 12 of Record:
Sharlene D. Falzone N/A N/A
Name Phone: Office# Mobile#
157 Lantana Drive 157 Lantana Drive
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 5123 Page No. 1655 Provide a copy of the most current deed.

Landowner 13 of Record:
Runnymeade Homeowner's Association Inc. N/A N/A
Name Phone: Office# Mobile#
Post Office Box 158 Lanier Avenue
Current Mailing Address Current Street Address
Gastonia NC 28053 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 3089 Page No. 40 Provide a copy of the most current deed.
Landowner 14 of Record:
Diane Ferro N/A N/A
Name Phone: Office# Mobile#
7996 Bluewater Bay Lane 216 Brookstone Drive
Current Mailing Address Current Street Address
Denver NC 28037 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4925 _ Page No. 944 _ Provide a copy of the most current deed.
Landowner 15 of Record:
SFR JV-1 2019-1 Borrower LLC N/A N/A
Name Phone: Office# Mobile#
1508 Brookhollow Drive 212 Brookstone Drive
Current Mailing Address Current Street Address
Santa Ana CA 92705 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 5070 Page No. 298 Provide a copy of the most current deed.
Landowner 16 of Record:
2018-4 IH Borrower LP N/A N/A
Name Phone: Office# Mobile#
1717 Main Street, Suite 200 208 Brookstone Drive
Current Mailing Address Current Street Address
Dallas TX 75201 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 5010 _ Page No. 669 _ Provide a copy of the most current deed.

Landowner 17 of Record:
Lori Oslund N/A N/A
Name Phone: Office# Mobile#
204 Brookstone Drive 204 Brookstone Drive
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 5357 Page No. 570 Provide a copy of the most current deed.
Landowner 18 of Record:
Xeng Chang N/A N/A
Name Phone: Office# Mobile#
417 Lanier Avenue 417 Lanier Avenue Extension
Current Mailing Address Current Street Address
Mount Holly _ NC 28120 Mount Holly _ NC 28120
City State Zip City State Zip
Deed Book No. 5221 _ Page No. 1759 Provide a copy of the most current deed.
Landowner 19 of Record:
Michael R. & Kenneth L. Plott N/A N/A
Name Phone: Office# Mobile#
426 Lanier Avenue 423 Lanier Avenue Extension
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4732 Page No. 765 _ Provide a copy of the most current deed.
Landowner 20 of Record:
Rickey L_& Shirley Jean Jennings N/A N/A
Name Phone: Office# Mobile#
123 Gray Fox Lane 425 Lanier Avenue Extension
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 5001 Page No. 1022 Provide a copy of the most current deed.

Landowner 21 of Record:
Tammy B. Legette N/A N/A
Name Phone: Office# Mobile#
500 Lanier Avenue Lanier Avenue Extension
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4976 Page No. 960 _ Provide a copy of the most current deed.
Landowner 22 of Record:
Tammy B. Legette N/A _ N/A
Name Phone: Office# Mobile#
500 Lanier Avenue 500 Lanier Avenue Extension
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 4976 Page No. 960 Provide a copy of the most current deed.
Landowner 23 of Record:
City of Mount Holly _ N/A N/A
Name Phone: Office# Mobile#
Post Office Box 406 Lanier Avenue Extension
Current Mailing Address Current Street Address
Mount Holly NC 28120 Mount Holly NC 28120
City State Zip City State Zip
Deed Book No. 590 Page No. 442 Provide a copy of the most current deed.