NCC222209_FRO Submitted_20220615

FINANCIAL RESPONSIBILITYIOWNERSHIIP 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 address
or phone number is unavailable, place NIA in the blank.)
Part A.
Project Name Sweetwater Subdivision, Phase 1-Lots 1-9 11-13, 15-19 25 & 57
Location of land -disturbing activity: County Cumberland City or Township Pea_ roes Mill Township
Emerald Stone Loop &
Highway/Stree Sapphire Stone Lane Latitude(deC1ma,degrees)_N34.9904'Longitude(decimaIdegrees) W-78.9364"
-3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.43 Acres _
6. Amount of fee enclosed: $ 700.00 . The application fee of $100.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed M No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Leslie Groves E-mail Address leslie roves hhhomes.corn
Phone: Office # 910-486-4864 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
H&H Constructors of Fayetteville. LLC
Name
3709 Raeford Road, Suite 200
Current Mailing Address
910-486-4864
Phone: Office # Mobile #
Same
Current Street Address
Fayetteville NC 28304 Same
City State Zip City State Zip
10. Deed Book No. 11484 Page No. 393 Provide a copy of the most current deed.

Part B.
1. Company(les) who are financially responsible for the land -disturbing activity (Provide a comprehensive
list of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the
landowner(s) is an individual(s), the name(s) of the owner(s) may be fisted as the financially responsible party(ies).
H&H Constructors of Fayetteville-LLC_
Company Name
3709 Raeford Road, Suite 200
Current Mailing Address
Fayetteville NC 28304
City State Zip
Phone: Office # 910-486-4864 Mobile #
Iesliegroves(a-)hhhomes.com
E-mail Address
Same
Current Street Address
Same
City State Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and
sedimentation control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party
is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name
under which the company is Doing Business As. If the Financially Responsible Party is an individual,
General Partnership, or other company not registered and doing business under an assumed name,
attach a copy of the Certificate of Assumed Name.
Company DBA Name
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(s) 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 Party). I
agree to provide corrected information should there be any change in the information provided
herein.
Leslie Groves
T, dorprintname
VP of Sales
Title or Authority
513� 2o22
Date
I, L &-t .� a Notary Public of the County of t.a111
State of North Carolina, hereby certify that CE' appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him/her.
Witness my hand and notarial seal,
this ,-day of , 20
No ry
- .�
X,
My commission expires