NCC203348_ESC Approval Submitted (2)_20200806

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Town of met
outhern Ines
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11 The Mid South Resort
Internationally Recognized for Program Excellence
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Public Works Department
140 Memorial Park Court
Southern Pines, North Carolina 28387
Telephone: [phone] — Fax: [phone]
No person may initiate any land -disturbing activity greater than 30,000 sq. ft. as covered by the Town's Code of
Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed and
approved by the Town of Southern Pines. (Please type or print and, if the question is not applicable or information
unavailable, place N/A in the blank.)
01i1e11
1. Project Name: Morganton Park North Lot 1 Grading and Erosion Control REVISED
2. Location of land -disturbing activity: County: Moore City or Township: Southern Pines
Street Address NW corner of Morganton Rd and Brucewood Rd
35 deg 10'36" N
3. Latitude:
Longitude: -79deg 25'18" W
4. Percent Impervious: o
5. Approximate date that land -disturbing activity will commence: April 2020
6. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial (stockpile)
7. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8
8. Amount of fee enclosed: $ 1,350
The application fee is $300.00 for the first acre plus $150.00 for each additional acre, or part thereof.
The revised plan review fee is $50 for each submittal after the 2nd review.
Any substantial revision to a previously approved, active plan is $50 per acre, or part thereof.
9. Has an erosion and sediment control plan been filed? Yes ® No ❑ Enclosed ❑
10. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Charles Gregg E-mail Address [e-mail]
Telephone [phone] Cell# 910-986-2023 Fax# [phone]
11. Landowner(s) of Record (attach accompanied page to list additional owners):
PACN Realty, LLC 910-235-2993 910-215-6038
Name Telephone Fax #
205 Page Road SAME
Current Mailing Address Current Street Address
Pinehurst NC 28374 SAME
City State Zip City State Zip
s210 269 12. Deed Book No. Page No. (Provide a copy of the most current deed).

Part B.
1. Person(s) or firm(s) who is financially responsible for the land -disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
Charles Gregg [e-mail]
Name
5 First Village Drive
E-mail Address
SAME
Current Mailing Address Current Street Address
Pinehurst NC 28374 SAME
City State Zip
City State Zip
Telephone [phone]
Fax# [phone]
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 of Registered NC Agent
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Telephone
Fax #
(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 NC Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Telephone
Fax #

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.
Charles Gregg
Type or print name
Signature
Member
Title or Authority
Date
, a Notary Public of the County of
State of North Carolina, hereby certify that
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 day of , 20
Notary
Seal
My commission expires
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED: June 2013