NCC242766_FRO Submitted_20241009

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or morn acres es covered by Ihn MJ hnlnin Ilan form
and an acceptable erosion and sedimentation control plan have been compintnrl and ,approved by the I and
Quality Section. N.0 Department of Environmental Qunlity Submit the completed Inrm In Ih.+ nt,lrrrq,rlutn
Regional Office (Please type or print and, if the question is not applicable or tfan n•na►d urlrlre•rn r,r i,lu,nn
number is unavailable, place N/A in the blank )
Part A.
1. Project Name Berkeley Place
2. Location of land-disturbing activity County Wayne City or Townsh►p_SaUISt0n
Highway/Street True Vine Rd (SR1568) 35 46984
Latitude(i,ec,, Corvine) L
,,r ongttude(.win ,d.pim.) __-- -
3. Approximate date land-disturbing activity will commence March 2023
4 Purpose of development (residential, commercial, industrial, institutional, etc ) Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 36
6. Amount of fee enclosed: $3,600 The application fee of$100.00 por acre (rounded
up to the next acre) is assessed without a ceiling amount (Example 8 10-acre application foe is $900)
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ® No p
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name `)u YI i Qr parl E-mail Address GQti YG LQri,gly\. $1OYS-4C ese jm6t ( (,on
Phone Office#(G 1 a)(1)3I.3 2-d l Mobile# (a.lq ) 60g - 5119 L4
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Carroll Construction Homes, Inc 919-639-3281
Name Phone Office# Mobile#
63 Veron Ct
Current Mailing Address Current Street Address
Willow Springs, NC 27592 •
City State Zip City State Zip
10. Deed Book No.3771 Page No. 359 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).
Carroll Construction Homes, Inc [e-mail]
Company Name E-mail Address
63 Veron Ct
Current Mailing Address Current Street Address
Willow Springs, NC 27592
City State Zip City State Zip
Phone: Office# 919-639-3281 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
CityState ZipCity State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the FinanciallyResponsible Partyis not a resident of North Carolina,
P Ca o a, 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
at on 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 1
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.
Rarold CT- Carrel 3 Presi4pn+
Type or print name Title or Authority
eA7Pt1231�3
Signature Date
I, Glerhanie, (' M ordian , a Notary Public of the County of 3-D1'IMS-OVI
State of North Carolina, hereby certify that {-}Qro 1 d G. c QrYP I, . appeared personally
f before me this day and being duly sworn acknowledged that the above form was executed by him/her.
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Witness my hand and notarial seal, this Z —day of jQnU Q , 20 23
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