NCC221193_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 Environment and Natural Resources. (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.
1. Project Name Saddlebrook Subdivision Phase 1
2. Location of land -disturbing activity: County Nash City or Township Rocky Mount
Highway/Street Green Hills Road Latitude 35.9947 Longitude-77.8835
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 41.61
6. Amount of fee enclosed: $ 2,731.01 . 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 John Coley E-mail Address [e-mail]
Telephone Cell # 919. 971.9772 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
John, Carmen and Barbara Coley 919.971.9772
Name Telephone Fax Number
517 Chrismill Lane
Current Mailing Address Current Street Address
Holly Springs NC 27540
City State Zip City State Zip
10. Deed Book No. 2022 Page No. 838-842 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
John Coley [e-mail]
Name E-mail Address
517 Chrismill Lane
Current Mailing Address Current Street Address
Holly Springs NC 27540
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 State
Telephone
E-mail Address
Current Street Address
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
E-mail 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.
John Coley
Type or print name
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Owner
Title or Authority
11-A.1 - z r
Date
I, VeAj'%a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledded that the above form was
executed by him.
Witness my hand and notarial seal, this J�e_da
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N VARNELLry Publich arolinabe County
My commission expires