NCC222027_FRO Submitted_20220527

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. Holl crest Additon No. 1
1. Project Name Holly
crest
Location of land -disturbing activity: County Moore City or Township Pinehurst
Highway/Street Linden Road Latitude35.487 Longitude-79.50
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): 8.5
6. Amount of fee enclosed: $ 900 . 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 Ken Bass E-mail Address [e-mail]
Telephone [phone]
cell # 910-528-6481 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bass Design and Dev. LLC
910-528-6480
Name
Telephone Fax Number
27 Chestertown Dr.
27 Chestertown Dr.
Current Mailing Address
Current Street Address
Pinehurst NC 28374
Pinehurst NC 28374
City State Zip
City State Zip
10. Deed Book No. 5753 Page No. 476-479 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.
Bass Design and Dev. LLC
[e-mail]
Name
E-mail Address
27 Chestertown Dr.
27 Chestertown Dr
Current Mailing Address
Current Street Address
Pinehurst NC 28374
Pinehurst NC 27374
City State Zip
City State Zip
Telephone [phone]
Fax Number

2. (a) If the Financially Responsible Party is not a rcsidmt of North Corofiria, egivc, name and strut address
of the d igr%�ied North Carolina AWt;
Alame— E-mail Address
Curront Matting Address �m Courant Street Address
City State P amity ro State Zip
°fAPPhorle — Fax Number
N It llae Financially ResponslVe Party is a Partrw.ship or other person enacging in buskie s under an
a finned name, attach a copy of the Certificate of Assumed tame. If the FRnenciaity Re ponsiWe
Party is a Corporatfon,give name; and street address of the Registerod Agent:
Narne of RegWered Agent
E-mail Addrer s
Currec7t Mailing A ddte=ss Current Street Address
city State dip �16i .�:-�� �— -- State Zip
Telcphono Fax Number,
The above information is Vue and correct to the best of my knowledge and belief and was, provid"
by rye tender mith ('f`his form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact:., or if riot an individual, by an officer, director-, partnor, or m, gistered agent with
the authority to extacute instruments for the Financially Responsible Person). l agree to provide
corrected inforni-olion shoOd there be any change in the information proviaded herein.
Ken Bass
Typ r print came
Signature
Title or Authority
Date
a Notary Pudic of the {;aunty of
f
State: of North Carolina, hereby certify that �� appeared
Personally before me this day and being dLAy s Chkamlodged that the above farm was
exee ailed by him.
Witnessrifay hand
.. LY
,a L
notarial seal, that: day Of � �°' e,-Oct , .20�
mI t. 11 :
lw
K06ryr
Icy commission expires A

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. Holl crest Additon No. 1
1. Project Name Holly
crest
Location of land -disturbing activity: County Moore City or Township Pinehurst
Highway/Street Linden Road Latitude 3-&..4$7 35.187 Longitude
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): 8.5
6. Amount of fee enclosed: $ 900 . 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 Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ken Bass E-mail Address [e-mail]
Telephone [phone] cell # 910-528-6481 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bass Design and Dev. LLC 910-528-6480
Name Telephone Fax Number
27 Chestertown Dr. 27 Chestertown Dr.
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
10. Deed Book No. 5753 Page No. 476-479 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.
Bass Design and Dev. LLC [e-mail]
Name
27 Chestertown Dr.
Current Mailing Address
Pinehurst NC 28374
City
E-mail Address
27 Chestertown Dr
Current Street Address
Pinehurst NC 27374
State Zip City
Telephone [phone] Fax Number
State
Zip