NCC220482_FRO Submitted_20220125

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
to}} Quality
No person may initiate any land -disturbing activity on one or more acre � rvi�e@TC%efore this form
and an acceptable erosion and sedimentation control plan have been�mpTed and approved by the Land
Quality Section, N.0 Department of Environmental Quality. Submit the compl�f@ t�gje appropriate
Regional Office. (Please type or print and, if the question is not applicable or the ill djb`f'{ax information
unavailable, place NIA in the blank.)
Part A.�lgh Regional Office
1. Project Name —Olive Branch Subdivision
2. Location of land -disturbing activity: County_Johnston City or Township_Wilson Mills
Highway/Street—West Olive Road Latitude_-78.4178 Longitude_35.5840
3. Approximate date land -disturbing activity will commence: June 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): _Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_5.0
6. Amount of fee enclosed: $_325 . 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 —Christopher Lyons E-mail Address —buddy lyons@leoterradevelopment .com_
Telephone_336-486-3653 Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_Leoterra Olive Branch, LLC
Name
_110-A Shields Park Drive
Current Mailing Address
_336-486-3653
Telephone
_Same
Current Street Address
Fax Number
_Kernersville, NC 27284 _Same
City State Zip City State Zip
10. Deed Book No._5665 Page No _484 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.) It the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party,
_ Leoterra Olive Branch, LLC _ buddy.lyons@leoterradevelopment com
Name E-mail Address
_110-A Shields Park Drive
Current Mailing Address
_ Kernersville, NC 27284
City State Zip
_Same
Current Street Address
_Sa
City
State
Zip
Telephone_336-486-3653 Fax Number

AF
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
Telephone
E-mail Address
Current Street Address
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:
-14ye-BeRke Cb 64PP44- LyOnS }�iIAAq, [e-mail]
Name of Registered Agent E-mbil Address
_110-A Shields Park Drive _Same
Current Mailing Address Current Street Address
_ Kernersville, NC 27284 _Same
City State Zip City State Zip
Telep hone-336A86-3653
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.
6K4-1'Ao l•er Lon 5 M ang ei-
Type r print name Title or AutMority
716laoai
Sin r Dat— a
1, Koe+ Dtm\t�P , a Notary Public of the County of MB Odsnbu{
State of North Carolina, hereby certify that Ghri 70 onS appeared
personally before me this day and being duly sworn ackno ledged Ofat the above form was executed
by him.
Witness my hand and notarial seal, this (04 day of to l , 20
tt%ti I I III Err111,
"',,''.� _V 40'
p� Notary Public Notary
Seal ? Mecklenburg r County ; My commission expiresN!? aoa3
My Comm. Exp. z—
y 08 26-2023
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