NCC215929_FRO Submitted_20211026

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Trinity Townhomes
1. Project Name
2. Location of land -disturbing activity: County Randolph city or Township Trinity
Highway/Street Intersection of SR 10041SR 1603 Latitude 35.896684 Longitude-79.981729
3. Approximate date land -disturbing activity will commence: Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.98 ac
6. Amount of fee enclosed: $ Already paid: Rando-2019-005 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).
R d plan ¢ncEoscd
7. Has an erosion and sediment control plan been filed? Yes No Enclosed a�sa
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jessica Meyer E-mail Address [e-mail]
Telephone [phone] Cell # NIA Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DR Horton NIA NIA
Name
Telephone Fax Number
2000 Aerial Center Parkway, Suite 110A
2000 Aerial Center Parkway, Suite 11 OA
Current Mailing Address
Current Street Address
Morrisville NC 27560
Morrisville NC 27560
City State Zip
City State Zip
10. Deed Book No. 002603 Page No.
00169 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.
DR Horton - Jessica Meyer
[e-mail]
Name
E-mail Address
2000 Aerial Center Parkway, Suite 110A
2000 Aerial Center Parkway, Suite 110A
Current Mailing Address
Current Street Address
Morrisville NC 27560
Morrisville NC 27560
City State Zip
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:
NIA
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State Zip
City State Zip
N/A
NIA
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:
DR Horton - Jessica Meyer
[e-mail]
Name of Registered Agent
E-mail Address
2000 Aerial Center Parkway, Suite 110A
2000 Aerial Center Parkway, Suite 110A
Current Mailing Address
Current Street Address
Morrisville NC 27560
Morrisville NC 27560
City State Zip
City State Zip
Telephone [phone] Fax Number NIA
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.
Jessica Meyer
Type or print name
Sig ture
Central Carolina NPDFS Technical Compliance Administrator
Title or Authority
Date
I, ,7o a Notary Public of the County of 7
State of North Carolina, hereby certify that A'4W_ appeared
personally before me this day and being duly sworn acknowledg d that the above form was
executed by him.
Witness my hand and notarial seal, this day of , 20_CLL_
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U[INA OTSINGEIirolg5CU TyrocNotary
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Seal { d D"3
My commission expires a a