NCC216751_FRO Submitted_20211207

.. I '' P01 1.11!UHL G
Errs ironmental Qual
Received
JUL 2 0 2021
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT Winston-Salem
Regional Office
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.
1. Project Name Charleston Ridge Dr. - Charleston Meadow Loop
2. Location of land -disturbing activity: County Davie City or Township Mocksville
Highway/Street Charleston Ridge Dr. Latitude 35,886985 Longitude-80.551853
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3 + 1 additional
6. Amount of fee enclosed: $ 195.00 + $65 additional . 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 Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeffrey R. Wilson E-mail Address [e-mail]
Telephone [phone] Cell # 336-399-4932 Fax #
9. Landowner(s) of Record (attach accompanied
page to list additional owners):
J. Ryan Group, LL.0
336-399-4932
Name
Telephone Fax Number
PO Box 527
2451 Spaugh Industrial Drive
Current Mailing Address
Current Street Address
Clemmons NC 27012
Winston-Salem NC 27103
City State Zip
City State Zip
10. Deed Book No. 1182 Page No.
825 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.
J. Ryan Group, LLC
[e-mail]
Name
E-mail Address
PO Box 527
2451 Spaugh Industrial Drive
Current Mailing Address
Current Street Address
Clemmons NC 27012
Winston-Salem NC 27103
City State Zip
City State Zip

Telephone [phone]c J2
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
State Zip
E-mail Address
Current Street Address
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:
Jeffrey R. Wilson [e-mail]
Name of Registered Agent E-mail Address
PO Box 527
Current Mailing Address
Clemmons NC 27012
City
State Zip
Telephone [phone]
2451 Spaugh Industrial Drive
Current Street Address
Winston-Salem NC 27103
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.
Jeffrey R. Wilson
Type or print name
,L'e,� 'd—)
LSfOafure
Member
Title or Authority
Date
a Notary Public of the County of L'i'
State of North Carolina, hereby certify that w F �..� , tj appeared
personally before me this day and being duly swo h ackr%wledged that the above form was executed
by him.
Witness my hand and notarial seal, this �U day of 20 I
/ OFFICIAL SEAL
w A Notary Public, North Carolina
COUNTY OF FOpSYTH
SANDHA KAY AUSTf N
My CornrnissiEtf�ires
Notary
My commission expires