NCC215587_FRO Submitted_20211008

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Somerton Subdivision
2. Location of land -disturbing activity: County Davidson City or Township Lexington
Highway/Street Bethesda Road Latitude 35-53-24 N Longitude 80-13-46 W
3. Approximate date land -disturbing activity will commence: October 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.64+/- acres
6. Amount of fee enclosed: $ 910.00 & $2,000.00 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
7.
Has an erosion and sediment control plan been filed? Yes No Enclosed x
8.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tim Grein
E-mail Address [e-mail]
Telephone [phone]
Cell # n/a Fax # n/a
9.
Landowner(s) of Record (attach
accompanied page to list additional owners):
Fat Porgy, LLC
919-348-2194 n/a
Name
Telephone Fax Number
150 Bunker Hill Court
150 Bunker Hill Court
Current Mailing Address
Current Street Address
Winston-Salem NC
27107 Winston-Salem NC 27107
City State
Zip City State Zip
10.
Deed Book No. 2488
Page No. 2287 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.
Fat Porgy, LLC [e-mail]
Name E-mail Address
150 Bunker Hill Court
Current Mailing Address
Winston-Salem NC
City
State
150 Bunker Hill Court
Current Street Address
27107 Winston-Salem
Zip City
NC 27107
State Zip

Telephone [phone] Fax Number n/a
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
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Latham -Walters Engineering, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Mitchell S. Latham, PE 704-895-8484 n/a
Individual contact person (type or print) 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.
Tim Grein L4 �' -�--
Type or print name Title or Authority
` r q ID �
Signature ©at
I, , � ,� 15 �2n�'.�� �l�#[' SO.�7 a Notary Public of the County of ED
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 _Zday of � - , 20
DL :Com
CHARMAINE JACKSON �', �a '-darkl�rl f
NOTAP-1 PUBLIC Notary
+'.n County
e. CarFolina
h&mission Expires March 11- 2023 My commission expires 4q- '?_0 2 3