NCC216526_FRO Submitted_20211208

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Williams Grove Phase 2 Lots 20-35
1. Project Name
2. Location of land -disturbing activity: County Nash City or Township Bailey
Highway/Street Stoney Hill Church Road Latitude 35.8123580 Longitude-78.0553920
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.0 Acres
6. Amount of fee enclosed: $ 2,520.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
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 Alan Mooring E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C.T. Williams Corporation [phone] N/A
Name Telephone Fax Number
3303 Sunset Ave, Suite H 3303 Sunset Ave, Suite H
Current Mailing Address
Rocky Mount
City
10. Deed Book No. 3032
Current Street Address
NC 27804 Rocky Mount NC 27804
State Zip City
Page No. 844
State
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.
WJH LLC
Name
[e-mail]
E-mail Address
3091 Governors Lake Drive, Suite 300 3091 Governors Lake Drive, Suite 300
Current Mailing Address
Norcross GA
City
Current Street Address
30071 Norcross GA
State Zip
City
State
30071
ME
Telephone [phone] Fax Number N/A

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:
Dave Hodgman
[e-mail]
Name
E-mail Address
1225 Eastchester Dr #107
1225 Eastchester Dr #107
Current Mailing Address
Current Street Address
High Point NC 27265
High Point NC 27265
City State Zip
City State Zip
Telephone [phone]
Fax Number NIA
(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:
NIA
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State Zip
City State Zip
Telephone N/A
Fax Number NIA
(c) In order to facilitate Express Permitting,
it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Ballentine Associates, PA
[e-mail]
Engineering Firm or other consultant
E-mail Address
Dillon W. Smith, PE
[phone] Ext. 111 [phone]
Individual contact person (type or print)
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.
Dave Hodgman
Type or print na
Regional President -Mid Atlantic Region
Title or Authority
a-17-Z,'I
Date
aL ea ID 1 Z , a Notary Public of the County of i
State of North Carolina, hereby certify that _ -4 j j f_ .O,O appeared personally
before me this day and being duly sworn acknowTecTd&d that the abo a form was executed by him.
Witness my hand and notarial seal, this ��day of 20
Tara Rabitz Notary
t RY PUBLIC
Wake County My commission expires
North Carolina
My Commission Expires November 9, 2i125