NCC221057_FRO Submitted_20220322

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. Olde Georgetown Ph 1 B
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Lockwood Folly
Highway/Street Camarosa Blvd SE Latitude 33.986 Longitude-78.2017
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 38.50
6. Amount of fee enclosed. $ . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kerry Avant E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DFC Groves at Olde Georgetown, LLC
910) 486-4864
Name
Telephone Fax Number
14701 Philips Hwy, Suite 300
14701 Philips Hwy, Suite 300
Current Mailing Address
Current Street Address
Jacksonville FL 32256
Jacksonville FL 32256
City State Zip
City State Zip
10. Deed Book No. 04734 Page No. 0729 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.
DFC Groves at Olde Georgetown, LLC
[e-mail]
Name
E-mail Address
14701 Philips Hwy, Suite 300
14701 Philips Hwy, Suite 300
Current Mailing Address
Current Street Address
Jacksonville FL 32256
Jacksonville FL 32256
City State
Telephone [phone]
Zip City
Fax Number
State Zip

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:
Kerry Avant - H&H Homes
[e-mail]
Name
E-mail Address
2919 Breezewood Avenue, Suite 400
2919 Breezewood Avenue, Suite 400
Current Mailing Address
Current Street Address
Fayetteville NC 28303
Fayetteville NC 28303
City State Zip
City State Zip
Telephone [phone]
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:
N/A
Name of Registered Agent
E-mail Address
Current Mailing 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.
C.H. Swan VIU_ -
Typ nor pri. t name Title or Authority
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Signature
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I �T-�riS�in� \nSoV—k
Flon da
State of North-Eafe4mifl87 hereby certify that _
personally before me this day and being
executed by him.
1"26-7
Date
, a Notary Public of the County of 1tA V
appeared
duly sworn acknowledged that the above form was
Witness my hand and notarial seal, this 2�i day of D\mUav� 20 2 2
Notary
Seal
My commission expires �t 2`I 2OZ2
CHRISTINA MINS0N
R+`irTr ourr<<
^r .State of Florida -Notary Public
•= Commission # GG 212417
My Commission Expires
`''+...'.. April 29, 2022