NCC222273_FRO Submitted_20220712

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1
2
3
4
5
6
7
8
Project Name Clark's Preserve Phase
Location of land -disturbing activity: County RockinghamCity or Township Reidsville
Highway/Street
216 Liberty Road LatltUde(decimal degrees) LOngltUde(decimal degrees) 36.32-79.696
Approximate date land -disturbing activity will commence:lu ne 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 47. 1 7
Amount of fee enclosed: $ 4, 800 . 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.
Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad E. Abbott E-mail [e-mail]
Phone: Office # 91 9-230-0996 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sandra Ransier Smith 336-514-6263 336-514-6263
Name
147 Deertrail Landing
Current Mailing Address
Reidsville NC 27320
Phone: Office # Mobile #
147 Deertrail Landing
Current Street Address
Reidsville NC 27320
City State Zip City State Zip
10. Deed Book No. 1 553 Page No. 531 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).
Southbury Development, LLC [e-mail]
Company Name
20 Cochran Castle Circle
Current Mailing Address
Pinehurst, NC 28374
E-mail Address
20 Cochran Castle Circle
Current Street Address
Pinehurst, NC 28374
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:
Southbury Development, LLC [e-mail]
Name of Registered Agent E-mail Address
20 Cochrane Castle Cir 20 Cochrane Castle Cir
Current Mailing Address Current Street Address
Pinehurst, NC 28374 Pinehurst, NC 28374
City State Zip City State Zip
Phone: Office # NA Mobile # [phone]
David Chapman
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:
NA NA
Name of Registered Agent E-mail Address
NA NA
Current Mailing Address Current Street Address
NA NA
City State Zip City State Zip
Phone: Office # NA Mobile # NA
NA
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.
Sa�cT1�,B,u�Y
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.
O,q 1/110 /fin/
Type or prin ame
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Signa ure
0WN45-9
Title or Authority
'Y/3f /' --Od-
Date
I,L.J c2fA SCFtQLLTc= , a Notary Public of the County of�Jers���
CALt�:OQn)(A ,&-
State of fit , hereby certify that a)c'..J appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/Vr.
Witness my hand and notarial seal, this a841% day of A-Qr-, L 20 Z Z
M- - - — a.
ELVIRASCHULTE Notary
_. Notary Public - California
Riverside County
Commission 9 Z397541
O.V Comm. Expires Apr 14, Lfi fi- My commission expires .Pr; L I <(� - oOA4,

dotloop signature verification: dtlp.us/n7tm-Tp0Y-xkem
LAND OWNER'S CONSENT TO FILE APPLICATION
dotloa2 verified
G� 0otloo M:04 AM EDT
UZ2N-2T3M-UNRP-ZBYH
(Legal Land Owner of Property) do
hereby authorize, David J. Chapman of Southbury Development (Applicant) and/or his assigns,
to make application for the property described by DB 1553 PG 53. This property is owned by
those listed and are hereby grant permission to the "Applicant" to apply, submit plans, interact,
accept permits, and commence construction / disturbance for the property referenced herein.