NCC220529_FRO Submitted_20220127

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. Ashe Meadows Subdivision Additional Erosion Control Plan
1. Project Name
2. Location of land -disturbing activity: County Meck/Unlon City or Township near Mint HIII
Highway/Street NC Hwy 218 Latitude 35010'16.77"N Longitude 80035'51.65"W
3. Approximate date land -disturbing activity will commence: January 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.66 acres
6. Amount of fee enclosed: $ 65 . 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 Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Johnathan McCall E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
B&C Land Farming LLC
704-774-1964
Name
Telephone Fax Number
2627 Brekonridge Centre Dr. Ste 103
2627 Brekonridge Centre Dr. Ste 103
Current Mailing Address
Current Street Address
Monroe NC 28110
Monroe NC 28110
City State Zip
City State Zip
10. Deed Book No. 35796 Page No. 786 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.
Carolina Development Services LLC
[e-mail]
Name
E-mail Address
2627 Brekonridge Centre Dr. Ste. 101
2627 Brekonridge Centre Dr. Ste. 101
Current Mailing Address
Current Street Address
Monroe NC 28110
Monroe NC 28110
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Wesley S. Hinson [e-mail]
Name of Registered Agent E-mail Address
309 Post Office Drive 309 Post Office Drive
Current Mailing Address Current Street Address
Indian Trail NC 28079 Indian Trail NC 28079
City
State Zip City
Telephone [phone]
Fax Number
State Zip
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.
G. David Cuthbertson
Type or print n
Signature -
Manager
Title or Authority
12/27/21
Date
I, & --PV' S S v ^ , a Notary Public of the County of Lk V-,\ U'-
State of North Carolina, hereby certify that C , Oav � C�- C,-'_j i,,n {f�­S C;- 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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