NCC221719_FRO Submitted_20220504

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. Sherwood Hills - Sherwood Ct. NW, Concord NC
1. Project Name
2. Location of land -disturbing activity: CountyCabarrus City or Township Concord
Highway/Street Sherwood Ct. NW Latitude35d25'25" N Longitude 80d37'09" W
3. Approximate date land -disturbing activity will commence: October 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreaae disturbed or uncovered (includina off -site borrow and waste areas):,
6. Amount of fee enclosed: $2 � � 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Todd Hicks
E-mail Address [e-mail]
Telephone
Cell # 704.292.3195 Fax #
9. Landowner(s) of Record (attach accompanied
page to list additional owners):
South Oak Partners, LLC
Name
Telephone Fax Number
P.O. Box 470643
7733 Ballantyne Commons Parkway, Suite 201
Current Mailing Address
Current Street Address
Charlotte NC 28247
Charlotte NC 28277
City State
Zip City State Zip
10. Deed Book No.14733 Page No.0309 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.
South Oak Partners, LLC
Todd@SouthOakPartners, LLC
Name
E-mail Address
P.O. Box 470643
7733 Ballantyne Commons Parkway, Suite 201
Current Mailing Address
Current Street Address
Charlotte NC 28247
Charlotte NC 28277
City State
Zip City State Zip
Telephone
Fax 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 E-mail Address
Current Mailing Address Current Street Address
City
State Zip City
Telephone 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
corrected information should there be any change in the information provided herein.
Type or print nam Title or Authority
Signature
Date
a Notary Public of the County of
State of North Carolina, hereby certify that -
personally before me this day and being
executed by him.
seal, this 0� 12 day of ���1� "��'�� i� ✓�" ; 20 J
Witn
appeared
duly sworn acknowledged that the above form was
Notary
My commission expires"