NCC216468_FRO Submitted_20211208

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 NIA in the blank.)
Part A. Sunset Ridge 11
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Sanford
Highway/Street Alpine Drive Latitude 35.312321 Longitude-79.035771
3. Approximate date land -disturbing activity will commence: 10/1 /21
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9
6. Amount of fee enclosed: $already pald . 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:
Name Charles Blackwell E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Allied Investors, Inc 910-433-0888-205
Name Telephone Fax Number
350 Wagoner Drive 350 Wagoner Drive
Current Mailing Address Current Street Address
Fayetteville NC 28303 Fayetteville, NC 28303
City State Zip City State Zip
10. Deed Book No. 1 145 Page No.674 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.
Sunset Ridge Development, LLC
Name E-mail Address
350 Wagoner Drive
Current Mailing Address Current Street Address
Fayetteville, NC 28303
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:
Sandhills Constractors, Inc
Name
E-mail Address
POB 1
2610 Lemon Springs Road
Current Mailing Address
Current Street Address
Sanford, NC 27331
Sanford, NC 27332
City State Zip
City State Zip
Telephone[phone]
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 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.
Charles D Blackwell Member
Title or Authority
I, Nei 1� V4RO Ose. -,a Notary Public of the County of CV*W"rj
State of North Carolina, hereby certify that v'f 451. �. �Jpjeywt-O appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness m,�,-`� }�r�ptarial seal, this ( day of 0` + C6 5-C , 20 Z1
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