NCC221651_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. Buies Creek Townhomes
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Neills Creek
Highway/Street 0 Gregory Circle Latitude N35.41814464 Longitude W78.74478741
3. Approximate date land -disturbing activity will commence: Summer of 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.24
6. Amount of fee enclosed: S 800 . 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:
Name Freddie Stancil E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Stancil Builders, Inc 919-639-2073
10
Name
466 Stancil Road
Current Mailing Address
Angier NC 27501
Telephone
466 Stancil Road
Current Street Address
Angier NC
City State Zip City
Deed Book No. 4025 Page No. 0371
State
Fax Number
27501
Zip
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.
Stancil Builders, Inc [e-mail]
Name
466 Stancil Road
Current Mailing Address
Angier NC 27501
City State Zip
Telephone [phone]
E-mail Address
466 Stancil Road
Current Street Address
Angier NC 27501
City State Zip
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 E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
(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:
Freddie Stancil
Name of Registered Agent
466 Stancil Road
Current Mailing Address
Angier NC
[e-mail]
E-mail Address
466 Stancil Road
Current Street Address
27501 Angier NC 27501
City State Zip
Telephone [phone]
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
corrected information should there be any change in the information provided herein.
nit-O'e-
pr-e'5. d end
Title or Authority
a-3-aoaa
Date
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I, S. s7> > a Notary Public of the County of A,2y- Il ek
State of North Carolina, hereby certify that Frc 54-Dnc;1 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
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