NCC221909_FRO Submitted_20220610

NC Department %F
Environmental Quali�y
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Received
SEDIMENTATION POLLUTION CONTROL ACT DEC 13 2021
No person may initiate any land -disturbing activity on one or more acres as covered byftlhb�fOmrjhis
form and an acceptable erosion and sedimentation control plan have been completedj� Iq�e by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the comped orm 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. Collybrooke Farm - Phase 1
1. Project Name
2. Location of land -disturbing activity: CountyRockingham City or TownshipNew Bethel
Highway/street NC Hwy 65 Latitude36.271620 Longitude-79.920352
3. Approximate date land -disturbing activity will commence: 1/3/2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 50.4 Ac.
6. Amount of fee enclosed: $ 5, 1 00 . 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:
NameJess Meyer E-mail [e-mail]
Telephone [phone] Cell 4 [phone] Fax 4
Landowner(s) of Record (attach accompanied page to list additional owners):
Collybrooke 2, LLC [phone]
Name Telephone
5826 Samet Dr., Ste 105
Current Mailing Address
High Point NC 27265
(same as mailing)
Current Street Address
City State Zip City
10. Deed Book No. 1 427 Page No.2475
State
[phone]
Fax Number
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.) Ifthe company orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
DR Horton c/o Jess Meyer [e-mail]
Name E-mail Address
2000 Aerial Center Parkway, Suite 110A
Current Mailing Address
Morrisville NC 27560
City
(same as mailing)
Current Street Address
State Zip City
Telephone [phone] Fax Number,
State
Zip

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
Current Street Address
City State
Zip City State Zip
Telephone
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 State Zip
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 name j Title or Authority
mac. ► C-1
SiOature Date
T�1 a Notary Public of the County of ro&s i y� �o�o%�
State of North Carolina, hereby certify that 14Gy5-k_ 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 ID - day of20 -;�%
C, AAR N
� 0 TA o � Notarya1 �"
�t I My commission expires
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