NCC215767_FRO Submitted_20211105

DocuSign Envelope ID: C1 FB9ECA-512D-41 EB-A804-01DC362C513685
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.
Project Name MILL CREEK COVE
2. Location of land -disturbing activity: County BRUNSWICK City or Township LOCKWOOD FOLLY_
Highway/Street SUNSET HARBOR ROAD Latitude33.9621 N_ Longitude78.2147 W
3. Approximate date land -disturbing activity will commence: AS SOON AS PERMITTED
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5
6
7
8
9
Total acreage disturbed or uncovered (including off -site borrow and waste areas):34_
Amount of fee enclosed: $2,210.00 PREVIOUSLY PAID_. 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).
Has an erosion and sediment control plan been filed? Yes X No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name DAVE HODGMAN E-mail Address [e-mail]
Telephone[phone] Cell # 336-362-6211 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
CP MILL CREEK LLC_
Name
12849 GORDON BOULEVARD
Current Mailing Address
WOODBRIDGE VA 22192
City State
Telephone
Current Street Address
Zip City
State
10. Deed Book No.4248 Page No.1178 Provide a copy of the most current deed.
Part B.
Fax Number
Zip
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.
WJH LLC
Name
3091 Governors Landing Rd, STE 300
Current Mailing Address
NORCROSS GA 30071
City
[e-mail]
E-mail Address
Current Street Address
State Zip City
State
Zip

DocuSign Envelope ID: C1 FB9ECA-512D-41 EB-A804-ODC362C5B685
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
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 Party
is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
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.
Dave Hodgman
Type or print name
FV
DocuSi ned by:
aVjN aV'
(AUKI61 F8A41 B...
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1, Teddi Tate Carr
Regional President
Title or Authority
10/14/2021
Date
----------------------------------------------------------
a Notary Public of the County of Guilford
State of North Carolina, hereby certify that Dave Hodgman 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 14th
TEDDI TATE CARR
Electronic Notary Public
Guilford County
Seal North Carolina
Commission Expires 7/14/2023
day of October
DocuSigned by:
N ota ry757B2769AFDF424...
.2021
My commission expires 7/14/2023