NCC221938_FRO Submitted_20220523

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 NIA in the blank.)
Part A.
1. Project
)�' I (_)'E�
2. Location of land -disturbing activity: County j a .0City or Township e-► k
S6 D
HighwaylStreetdiQnC.�n Latitude:!� Longitude — 7131•
3. Approximate date land -disturbing activity will commence: ' 20.2;t
4. Purpose of development (residential, commercial, industrial, institutional, etc.): I
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): r
6. Amount of fee enclosed: $ �� 00 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name , C�-�� E-mail Address cXC��� Imo '+�'� ' GO'�
Telephone Cell # o 3 4 3 D164 Pax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
V rGC.n to Mz A._ {
Current Mailind Address Current Street Address
HouS4 --rX 7 70-4d
City State Zip city State
State Zip
10. Deed Book No. � Q l 0 � Page No. DT 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.
Camden Development Inc [e-mail]
Name
11 Greenway Plaza Ste 2500
Current Mailing Address
Houston, TX 77046
ity I State Zip
E-mail Address
Current Street Address
City State
Zip

Telephone q03 9-3o 2-464 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 State Zip
Telephone,
E-mail Address
Current Street Address
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:
ca��
Name of Registered Agent E-mail Address
,;�.2.3 S. WUZS s s q00
Current Mailing Address
?T�61' nJif� 7l�
City State Zip
Telephone ` 6qo 7,38!1
Current Street Address
City
Fax Number
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 planandits preparation.
�(1�d./Y1.S Uoirx�pyon Abe-YC]�aof] ,( D�.�Q'�%l�or� �C/Y�GtThSC'.O. C'D!�
Engineering Firm or other consultant E-mail Address
`SQ,.A- j?01de4_S1_n 1//9 a8"70Ais
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.
h a tq ej K C, iq :1::�) it V-�C—
T it name Title or Authority
Signature If5fe
I, _LL.n+4W1 Goi,vie, Joe • _ a Notary Public of the County of lAIAL
State of North Carolina, hereby certify that �V4GLYiQ, s, OAk4__�epa 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 U�'day of 2022,
THEi BOONE JR Notary
LSeAr'N
Notary Publicke Co., North Carolina My commission expiresmission Fxpires Oct. 27, 2024