NCC217004_FRO Submitted_20220120

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 N/A in the blank.)
Part A.
Project Name The Farm at Neill's Creek
2. Location of land -disturbing activity: County Harnett City or Township Neill's Creek
Highway/Street NC 210 Latitude 35.454828 Longitude 78.791769
3. Approximate date land -disturbing activity will commence: April 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.)
residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 87.9+0.7=88.6 ac
6. Amount of fee enclosed: $ 5,720+65=5,785 . 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 Trevor Dalton E-mail Address—[e-mail]
Telephone
Cell # 919-219-7927 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dan Ryan Builders -North Carolina, LLC
Name
3000 RDU Center, Suite 202
Current Mailing Address
Morrisville NC 27560
City State Zip
919-747-4970
Telephone
Current Street Address
City
State
Fax Number
10. Deed Book No. 3963 Page No. 731 Provide a copy of the most current deed.
Part B.
Zip
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.
Dan Ryan Builders -North Carolina, LLC
Name
3000 RDU Center, Suite 202
Current Mailing Address
ilewis(a�drbgroup.com
E-mail Address
Current Street Address
Morrisville NC 27560
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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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.
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State of North Carolina, hereby certify that CO 1 S appeared
personally before me this day and being duly sw rn acknowledged that the above form was
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