NCC220220_FRO Submitted_20220111

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: Union Hills, Phase 1 - Lots 1-6, 10-12, 16, 19, 21 & 25-27
2. Location of land -disturbing activity: County Moore City or Township Carthage Township
Union Church Road (SR 1805)
Highway/Street & Century Lane atitude N 35.3132' Longitude W-79.34790
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.95 Acres
6. Amount of fee enclosed: $900.00. The application fee of $100.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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(cDhhhomes. com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
H&H Constructors of Fayetteville, LLC
Name
2919 Breezewood Avenue, Suite 400
Current Mailing Address
Fayetteville NC 28303
City State Zip
480-787-1911
Telephone
Same
Current Street Address
City
Fax Number
State Zip
10. Deed Book No. 5764 Page No. 576 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
H&H Constructors of Favetteville, LLC
Name
2919 Breezewood Avenue, Suite 400
Current Mailing Address
Fayetteville NC 28303
City State Zip
Telephone [phone]
JenniferGardner hhhomes.com
E-mail Address
Same
Current Street Address
Same
City State Zip
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 Mailirg Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
Zip
(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
Type or print name
Signature
-------------------------------------------------------------
Agent
Title or Authority
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Date
I , Ani(iJ Ld3 J 1 LL d'e r.1 a Notary Public of the County of Hyr 4?
State of North Carolina, hereby certify that C ' Q. 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
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Seal �NO�Aiy
MY
�oMMISSIdN EXPIRES
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PUBLIC
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