NCC216077_FRO Submitted_20211104

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. chapel ridge lot 718
1. Project Name P g
2. Location of land -disturbing activity: County Chatham City or Township Pittsboro
Highway/street 410 berry patch Latitude 35.7947 Longitude-79.2191
3. Approximate date land -disturbing activity will commence: nov. 18,2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '36
6. Amount of fee enclosed: $ 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Steve Satterwhite E-mail Address [e-mail]
9196307443 cell # 9196307443 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
robert and nicollette galvin 9197490703
Name
3405 antlerview dr
Current Mailing Address
apex nc 27502
Telephone Fax Number
3405 antlerview dr
Current Street Address
apex nc 27502
City State
Zip City State Zip
10. Deed Book No. 2220
Page No. 0188 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 orfrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
mcs homes
[e-mail]
Name
E-mail Address
624 royal tower way
624 royal tower way
Current Mailing Address
Current Street Address
Cary nc 27513
Cary nc 27513
City State
Zip City State Zip
Telephone [phone]
Fax Number

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
Telephone Fax Number.
State Zip
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.
Steve Satterwhite
Type or arint name
Signature
president
Title or Authority
10/29/2021
Date
I, VG�4Pif �� Munn a Notary Public of the County of \Make_
State of North Carolina, hereby certify that S1lf_ye Sa4erwk.t �P_ 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 o?.gday of 20-9—_
JJ0,41a,
........ Giti Notary
My commission expires 07 -Z(D— 7-05
A�/B L I G ; G