NCC215658_FRO Submitted_20211013

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 Environment and Natural Resources. (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 Sierra Village at Overhills Lots 6, 48 and 49
2. Location of land -disturbing activity: County Harnett City or Township Anderson Creek
Highway/Street Dakota Court Latitude 35.2512970 Longitude-78.9385870
Approximate date land -disturbing activity will commence: August 06, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.98 acres
6. Amount of fee enclosed: S 65.00. The application fee of $65.00 per acre (rounded up to the next acre) is assessed
without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Benjamin Stout
Telephone [phone]
E-mail Address ben benstoutconstruction.com
Cell # 910476-4502 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Benjamin Stout Real Estate Services, Inc.
Name
PO Box 53798
Current Mailing Address
Fayetteville NC 28305
City State Zip
910-476-4502
Telephone
409 Chicago Drive
Current Street Address
NIA
Fax Number
Fayetteville NC 28305
City State Zip
10. Deed Book No. 3949 Page No. 173 Provide a copy of the most current deed.
Deed Book No. 3996 Page No. 411 Deed Book No. 3949 Page No. 173
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Benjamin Stout Real Estate Services, Inc.
Name
PO Box 53798
Current Mailing Address
Fayetteville NC 28305
City State Zip
bensl_out ,hotmail.com
E-mail Address
409 Chicago Drive
Current Street Address
Fayetteville NC 28305
City State Zip
Telephone [phone] Fax Number NIA

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
Current Mailing Address
E-mail 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone Fax N
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.
Type or rint nane
Signature
President
Title or Authority
Date
I, , a Notary Public of the County of d
State of North Carolina, hereby certify tha&ijotmin appeared personally before me this
day and being duly sworn acknowledged that thJ above form was executed by him.
Witnes,§,wy1NAHtl1a4 notarial seal, this
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