NCC215831_FRO Submitted_20211020

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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.
Wayside1. Project Name Wayside Road Apartments
2. Location of land -disturbing activity: County Hoke City or Township
Highway/Street Brock Road Latitude 35.038887 Longitude-79.106996
3. Approximate date land -disturbing activity will commence: September 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): 17.7
6. Amount of fee enclosed: $ f 70 + 2000 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Dino Hackett
E-mail Address dhack56C aol.com
Telephone [phone] cell # 336-362-2041 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to fist additionat owners):
Hackett Properties, Inc.
336-674-2443 336-674-2443
Name
Telephone Fax Number
1152 Kerns -Hackett Road
1152 Kerns -Hackett Road
Current Mailing Address
Current Street Address
Pleasant Garden NC 27313
Pleasant Garden NC 27313
City State Zip
City State Zip
10. Deed Book No. 1087 Paae No. 1
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 paq-
Hackett Properties, Inc
[e-mail]
Name
E-mail Address
1152 Kerns Hackett Road
Current Mailing Address
Current Street Address
Pleasant Garden NC 27313
City State Zip
City State Zip
Telephone [phone]
Fax Number 336-674-2443

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
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
:'arty is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
4D Site Solutions, Inc
Engineering Firm or other consultant
Scott Brown, PE
[e-mail]
E-mail Address
910-426-6777 910-426-5777
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.
Type— or pname
`/7 e j Le�i
Signature
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that ,jV l--�((22{ !�(_� 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
MICHELE K FEENEY
L
otary Public - North Carolina Notary
Guilfo§Ydo y.
ommission Expires My commission expires