NCC216503_FRO Submitted_20211119

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 Environment and Natural Resources. (Please type or print and,
if the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name: The Manors at Lexington Plantation, Part 2D - Lots 682-686 & 688
2.
3. Location of land -disturbing activity: County Harnett City or Township Anderson Creek
Princelet PT &
Highway/Street Bow Common Way Latitude N 35.2679' Longitude W- 79.0188'
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.50 Acres
6. Amount of fee enclosed: $ Already 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).
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 Brian Walker E-mail Address brianwalker(a7hhhomes.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
H&H Constructors of Fayetteville, LLC 910-486-4864 910-485-0463
Name Telephone Fax Number
2919 Breezewood Ave., Ste. 400 Same
Current Mailing Address Current Street Address
Fayetteville NC 28303 Same
City State Zip City State Zip
10. Deed Boom No 4060 Page No 010 Provide a copy of the most current deed
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties an an attached sheet):
H&H Constructors of Fayetteville, LLC
Name
2919 Breezewood Ave., Ste. 400
Current Mailing Address
brianwalker ccDhhhomes.com _
E-mail Address
Same
Current Street Address
Fayetteville NC 28303 San
City State Zip City
State Zip
Telephone [phone] Fax Number 910-485-0463

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
E-mail 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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
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.
Brian Walker Anent
Type or print name Title or Authority
l rD Izz Z(
Signature Dat
0.lL-�j, za L)a. eq a Notary Public of the County of i WKcl
State of North Carolina, hereby certify that e-"I' O_f k1__ <c.._ke i- 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 28 day of (-) CML' er , 20 21
xs T" NaTAq), G
Seal = caN4my
,36"
ex
nzz PW*s
0
pUBLr �,'
OV N4V'_1
Notary
My commission expires