NCC221332_FRO Submitted_20220406

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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. Hawley Property
1. Project Name
9
Location of land -disturbing activity: County.
Highway/Street Old Coats Road
Harnett
City or Township Lillington
Latitude 35.42583 Longitude
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
-78.79250
Residential
16.7
6. Amount of fee enclosed: $ 2,000 + $1,700 = $3,700 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert C. Stuart
E-mail Address [e-mail]
Telephone [phone] Cell # 919-796-6363 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Chad Andrews Hawley %-7 4$DI
Name Telephone
310 River Road
Current Mailing Address
Fuquay-Varina NC 27526
City State Zip
10. Deed Book No. 3544
310 River Road
Current Street Address
Fuquay-Varina NC
City State
Fax Number
27526
Zip
Page No. 0266 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.
r tK RC [e-mail]
Name E-mail Address
2000 Aerial Center Parkway, Suite 110
Current Mailing Address
Morrisville NC 27560
City
State Zip
2000 Aerial Center Parkway, Suite 110
Current Street Address
Morrisville NC 27560
City State Zip

Telephone[phone] (m)919-796-6363 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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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 N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
The Nau Company, PLLC [e-mail]
Engineering Firm or other consultant E-mail Address
Brian Okane, PE 252-702-1910
Individual contact person (type or print) 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-'Ipe � �rgation_ prole_d ��rein.
fype or pr t name Title or Authority
/-ZV2Z
Signature Date
6 w-
a Notary Public' of the County of T 04a
State of North Carolina, hereby certify that "ylr&tt4 (t (/ ( 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 ��i day of 20 2
S ELAINE HUDSPETH
Notary Public Notary
Seal North Carolina tC G4 WLZ
My commission expires
Forsyth County