NCC222383_FRO Submitted_20220630

hENDERS A
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
CITY OF HENDERSONVILLE
SOIL EROSION AND SEDIMENTATION CONTROL
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 Environment and Natural Resources. (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 Name Waterleaf at Flat Rock Apartments
2. Location of land -disturbing activity: County Henderson City or Township Hendersonville
Address of Project: S. Allen Road Latitude 35.2999 Longitude-82.4153
3. Approximate date land -disturbing activity will commence: August 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.0
6. Amount of fee enclosed: $ 4,700 . Fee Schedule FY 2018-2019 is available on
Water Resources at link https://www.hendersoncountync.gov/waterresources/page/approved-
fees-fy-2018-2019-0.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
L-0
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Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Seth Peterson
[e-mail]
Name
E-mail Address
P.O. Box 17437
200 East Broad Street, Suite 220
Current Mailing Address
Current Street Address
Greenville SC 29606
Greenville SC 29601
City State Zip
City State Zip
[phone]
Telephone Cell #
Landowner(s) of Record (attach accompanied
page to list additional owners) NOTE: Must match
Henderson County Courthouse - Land records
information or provide a recorded deed:
Peggy Cabe, Enna Camenzind, Paula Carter, Robert Camenzind, Joan Fleming
Name
Telephone Fax Number
5133 Boylston Hwy
5133 Boylston Hwy
Current Mailing Address
Current Street Address
Mills River NC 28759
Mills River NC 28759
City State Zip
City State Zip
City of Hendersonville FRO.doc Revised 6-19-2018

10. Deed Book No. 3754
Page No. 155
Provide a copy of the most current deed.
Part B.
1. Person(s) or firms who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet) NOTE: The signature of a
corporation, or LLC must be a listed member on the formation documents on file with the
state office at https://www.sosnc.gov/search/index/corp.
Waterleaf at Flat Rock Apartments, LLC [e-mail]
Name E-mail Address
P.O. Box 17437 200 East Broad Street, Suite 220
Current Mailing Address Current Street Address
Greenville Sc 28606 Greenville Sc 28601
City State Zip City State Zip
Telephone [phone]
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:
Incorp Services, Inc.
Name E-mail Address
176 Mine Lake Court, Suite 100 176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone
(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's a Corporation, give name and street address of the Registered Agent:
Rare
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone
State Zip
City of Hendersonville FRO.doc Revised 6-19-2018

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.
Paul Aiesi
nre
Manager
Title or Authority
Date
I, V-Q%y- �QY1 , a Notary Public of the County of r(t er\.ri' ll 2
So orDti nck
State of Ne=t �lina, hereby certify that VGyl ;)ie S, 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 I S day of �'�u{i V--\ , 20 2 Z
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City of Hendersonville FRO.doc Revised 6-19-2018