NCC221218_FRO Submitted_20220330

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. Cool Springs Mitigation Site
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Broadway
Highway/Street Holly springs church Road Latitude 35026'50.17"N Longitude 78058'5.78"W
3. Approximate date land -disturbing activity will commence: April 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Mitigation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 36.7
6. Amount of fee enclosed: $ 3,700 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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:
NameJeff Keaton
E-mail [e-mail]
Telephone [phone] cell # 919-302-6919 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Patterson and Sons, Inc.
919-499-3128
Name
Telephone Fax Number
78 Tim Patterson Lane
78 Tim Patterson Lane
Current Mailing Address
Current Street Address
Broadway, NC 27505
Broadway, NC 27505
City State Zip
City State Zip
10. Deed Book No. 4089 Page No. 63 - 74 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Wildlands Engineering, Inc.
[e-mail]
Name
E-mail Address
312 W Millbrook Rd. Suite 225
12 W Millbrook Rd. Suite 225
Current Mailing Address
Current Street Address
Raleigh, NC 27609
Raleigh, NC 27609
City State Zip
City State Zip
Telephone [phone] x 102 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
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
correctedjnformation should there be any change in the information provided herein.
Jot* VfuttQry _ Vice President
Sig
Title or Authority
_3/auk
Date
I, _ �� !` i �� a Notary Public of the County of A41'f
State of North Carolina, hereby certify that V04 a0011 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 c2a day of, R!L/ , 20 vZt2
_ 0 Tq ,`0^'; Notary
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