NCC221712_FRO Submitted_20220505

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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.
1. Project NameOak Ridge Subdivision
2. Location of land -disturbing activity: County Ravidson City or Township Lexi ngton
Highway/Street Peaccock Ave Latitude35.812345 Longitude-80.277639
3. Approximate date land -disturbing activity will commence: May 2, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 14
6. Amount of fee enclosed: $1400(2000) The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameChris Reid E-mail Addresschris @ reidfarm.com
Telephone[phone] Cell # 336-250-0483 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Davidson Land Development, LLC 336-250-0483 n/a
me
896 Shiptontown Rd
Current Mailing Address
Lexington NC 27292
City State Zip
10. Deed Book No.2528 Page No.
Telephone
Fax Number
896 Shiptontown Rd
Current Street Address
Lexington NC 27292
City State Zip
417
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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Davidson Land Development, LLC [e-mail]
Name
896 Shiptontown Rd
Current Mailing Address
Lexington NC 27292
City State Zip
Telephone [phone]
E-mail Address
896 Shiptontown Rd_
Current Street Address
Lexington NC 27292
City State Zip
Fax Number n/a

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
Name
n/a
Current Mailing Address
n/a
City State
Telephone n/a
n/a
E-mail Address — — —
n/a
Current Street Address —
n/a
Zip City State
Zip
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 cagy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Chris Reid
Name of Registered Agent
896 Shiptontown Rd
Current Mailing Address
Lexington NC 27292
city
state
Telephone [phone]
[e-mail]
E-mail Address
896 Shiptontown Rd
Current Street Address
Lexington NC 27292
Zip City
Fax Number n/a
State Zip
(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:
Summey Engineering Associates, PLLC christian @summeyengineering.com
Engineering Firm or other consultant
Christian Vestal E-mail Address
Individual contact person or (type print 336-328-0902 33fi-328-0922
) 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.
Type or print n e Title or Authority
Signature 16 1 �1122
--------------------- Date
i n q N°y'°, .a Notary Public of the County of
State of North Carolina, hereby certify that C-hri s
before me this day and being duly sworn acknowledged thaWthe above form was executed b
appeared personally
y him.
witness my hand and notarial seal, this 1.
day of r; 1 20 �a
a
NDA H COVINGTON Notary
ublic - North Carolinavidson Countyon Expires Sep 26, 2025 MY commission expires