NCC221560_FRO Submitted_20220422

NC Department of
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Environmental Quality
Received
SEDIMENTATION POLLUTION CONTROL ACT MAR 3 1 2
EXPRESS PERMITTING OPTION 022
No person may initiate any land -disturbing activity on one or more acres as covered by the Ac &gPAhfi krm
and an acceptable erosion and sedimentation control plan have been completed and appr dcryallh® fj�@d
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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name SUMMERHAVEN EAST PHASE 1
2. Location of land -disturbing activity: County ALAMANCE City or Township MEBANE
H WY 119 36.051393-79.320481
Highway/Street LatltUde(decima� degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: SPRING 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.53 ACRES
6. Amount of fee enclosed $4,000 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name JESSICA MEYER E-mail Address [e-mail]
Phone: Office # 919-215-6561 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton, Inc. 919-215-6561
Name
4150 Mendenhall Oaks Pkwy
Current Mailing Address
HIGH POINT NC
City
State
Phone: Office # Mobile #
4150 Mendenhall Oaks Pkwy
Current Street Address
27265 HIGH POINT NC
Zip City State
27265
Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

2. (a) If the Financially Responsiole 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Evans Engineering, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Lee Bryant 336-279-7451 336-854-8877
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 the information provided herein.
JESSICA MEYER
Type or print name
A
NPDES MANAGER
Title or Authority
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Date
a Notary Public of the County of �b�Y
State of North Carolina, hereby certify that ���c� ��`��- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed bye. lAer-
Witness my hand and notarial seilaie�, '� day of Jv�+z� / 20 22
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Seal
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