NCC242147_FRO Submitted_20240723

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part A.1 . Project Name New Elam Woods Lot N
2. Location of land-disturbing activity: Countychatham City or Townshipnew hill
Highway/Street 198 Hidden Field Latitude 35.662 Longitude'79•055
3. Approximate date land-disturbing activity will commence:7115/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.):residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): '955
6. Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kirk T. Melly E-mail [e-mail]
Telephone Cell # 919.235.2077 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bill White 919.244. 1384
Name Telephone Fax Number
198 Hidden Field 198 Hidden Field
Current Mailing Address Current Street Address
New Hill NC 27562 New Hill NC 27562
City State Zip City State Zip
10. Deed Book No.02030 Page No.0692 Provide a copy of the most current deed.
Part B.
1 . Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
The Tuscan Group, Inc tuscangroupinc©gmail.com
Name E-mail Address
661 Cedar Grove Rd 661 Cedar Grove Rd
Current Mailing Address Current Street Address
Pittsboro NC 27312 Pittsboro NC 27312
City State Zip City State Zip
Telephone�19.235'2077 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.
Kirk T. Metty President
Type orjobo ,e-F - ; 4,8•••• Title or Authority
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Signature Date
I, COrri P 1(li C. , a Notary Public of the County of Onattaryi
State of North Carolina, hereby certify that ie1 ( , -T. Wik. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this i 1 day of 3u H , 20 r}4
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