NCC216236_FRO Submitted_20211112

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. Hayward House
1. Project Name
2. Location of land -disturbing activity: County Caswell City or Township Yanceyvllle
Highway/Street Lake Pointe Drive Latitude36.375914 Longitude-79.375056
3. Approximate date land -disturbing activity will commence: Upon Permitting
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.3 acres
6. Amount of fee enclosed: $ 390.00 . 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 No XX Enclosed XX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name W.A. Hayward
Telephone [phone]
E-mail Address n/a
Cell # 336-260-5212 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Susan Hayward & Spouse W.A. Hayward 336-260-5212
10.
Name
552 Meadowood Drive
Current Mailing Address
Burlington, NC 27215
City
n/a
Telephone Fax Number
552 Meadowood Drive
Current Street Address
Burlington, NC 27215
State Zip City
Deed Book No. 633 Page No. 997
State
Zip
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.
W.A. Hayward n/a
Name
552 Meadowood Drive
Current Mailing Address
Burlington, NC 27215
City State
Telephone [phone]
E-mail Address
552 Meadowood Drive
Current Street Address
Burlington, NC 27215
Zip City
Fax Number n/a
State
Zip

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:
n/a
Name
Current Mailing Address
City
Telephone.
State
Zip
E-mail Address
Current Street Address
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:
n/a
Name of Registered Agent
Current Mailing Address
City State
Telepho
E-mail Address
Current Street Address
Zip City State Zip
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 print na e j �;// Title or Authority
4 --�
Signature
Date
1, ,� � i�i, ��l i' a Notary Public of the County of ldir q tt
State of North Carolina, hereby certify that ff 4 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 G 1rd/,-i' 20
JANET A BARKER
.4WY PUBLIC
ALAMANCE COUNTY
North Carolina
My Commission Expires February 7, 2023
Notary
My commission expires
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