SW6130901_HISTORICAL FILE_20130523

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW 44�f 19
DOC TYPE
❑ CURRENT PERMIT
❑ APPROVED PLANS
7W HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
o20C'Jla��
YYYYMMDD

Anderson Engineering & Assoc., P.A.
PO. Box 1736 Larry W. Anderson, P.E.
305 North Chippewa Street President
Lumberton, N.C. 28359
Licensure No.: C-0793
LETTER OF TRANSMITTAL
DATE: MAY 23, 2013 PROJECT: Stone Gables Apartments
TO: NCDENR — Fayetteville Regional Office S[ormwater Permit No. SW6130901
Land Quality Section Hoke Co
Stormwater Permitting
225 Green St.. Suite 714
Fayetteville, NC 28301
WE ARE SENDING YOU NAttached ❑Under separate cover viz
El Shop Drawings ❑Prints ❑Plans
LISPS the following items
❑Samples ❑Specifications
❑Copy of letter ❑Change Order ® Designer's Certification
COPIES
DATE
NO.
DESCRIPTION
1
05/23/2014
One original of the Designer's Certification for the Stormwater Wet Detention Pond
! MAY 2 7 2014
THESE ARE TRANSMITTED as checked below:
❑ For approval
® For your use
❑As requested
❑ For review and comment
❑FOR BIDS DUE
Remarks:
❑Approved as submitted
❑Approved as noted
❑ Returned for corrections
Copy To: Project File
Mike Lawyer, NCDENR (email)
Aaron Thomas, Township Developers (email)
James Maynor, Township Developers (email)
Greg Hunt, Metcon (email)
Dino Hackett, Stone Gables Apartments (email)
Brad Stanley, McArthur Construction (email)
Larry Anderson, Anderson Engineering (email)
❑ Resubmit _copies for approval
❑Submitcopies for distribution
❑Return _corrected prints
❑ Prints returned after loan to us
SIGNED: SAMUELJ. POWERS, P.E.
National Society of
Professional Engineers®
Phone: [phone] • Fax: [phone] • Email: andersonengineeringpa 0agmail.com

Anderson En
P.O. Box 1736
305 North Chippewa
Lumberton, N.C. 28359
Licensure No.: C-0793
August 29, 2013
Attn: F
NCDET
1601 M
Raleigh
F'R41
Mr. Bei
Please I
review
• disturbing activities
• One copy of the Stormwater Management Report for the project which includes the
following items:
o Detailed narrative describing the stormwater management for the project
o USGS map identifying the site location
o Sealed, signed and dated calculations
o Soils report with associated SFI WT elevations
o Table of Elevations. Areas. & Volumes
INNational ftelety of
Professional Engineers®
%veering & Assoc., P.A.
Larry Anderson, P.E.
President
Phone: [phone] • Fax: [phone] • Email: [e-mail]

NCDENR-DWQ
August 30, 2013
Page 2 of 2
• One copy of Plan Sheet COO
— "Existing Conditions/Demolition Plan'
• One copy of Plan Sheet C100
— "Overall Site Plan'
• One copy of Plan Sheet C203
— "Stornwater Management Plan'
• One copy of Plan Sheet C704
— "Erosion Control Details"
• One copy of Plan Sheet C711
— "Stormwater Management Details'
• One copy of the "Recombination Survey for Venture Properties Group LLC"
Should you require any additional information, please do not hesitate to contact me.
Sincerely,
ANDERSON ENGINELRfNG & ASSOCIATES, P. A.
J.
Enclosures
cc (electronic copy — letter only): Danny Paschal - Hoke County Building Inspections
Dino Hackett - Hackett Builders, Inc.
Greg Hunt - Metcon, Inc.

1084 8KO1084 PG:0530
0530
FILED
HOKE COUNTY NC
CAMILLE D. HURST
FILED
Jul 15, 2014
TIME
04:04:04 pm
BOOK
01084
START PAGE
0530
END PAGE
0534
INSTRUMENT
# 03902
RECORDING
$26.00
EXCISE TAX
ELa (None)
NORTH CAROLINA AGREEMENT AND JOINDER IN THE
DECLARATION OF EASEMENTS AND
COVENANTS, CONDITIONS AND
RESTRICTIONS FOR STONE GATE
HOKE COUNTY VILLAGE as recorded in Book 1068, Page
856
This Agreement and Joinder in the Declaration of Easements and Covenants, Conditions
and Restrictions for Stone Gate Village (this "Joinder) is entered into this 18th day of March,
2014 by Lumbee River Electric Membership Corporation, a North Carolina Electric Cooperative
("LREMC" ). Venture Properties Group, LLC, a North Carolina limited liability company,
Township Developers, a North Carolina limited liability company, HC AL Investors, LLC, a
Virginia limited liability company, and Stone Gables Apartments, LLC, a North Carolina limited
liability company shall be indexed Grantees to this Joinder (the "Grantees").
WHEREAS, LREMC owns certain real property situated in a commercial development
known as Stone Gate Village located in McLaughlin Township, Hoke County, North Carolina,
said real property being more particularly described as Tract 1 on the plat entitled
"Recombination Survey for Venture Properties Group LLC" by Michael J. Adams, P.L.S. dated
August 11, 2011, recorded in Cabinet 4, Slide 4-28 Map 004, Hoke County Registry which is by
this reference incorporated herein (the "Property"),

1084'
0531 BK:01084 PG:0531
WHEREAS, pursuant to that certain DECLARATION OF EASEMENTS AND
COVENANTS, CONDITIONS AND RESTRICTIONS for Stone Gate Village recorded in
Office of the Register of Deeds of Hoke County, North Carolina on February 7, 2014 at Book
1068, Page 856 (the "Declaration') LREMC was granted the right to join in the Declaration
without further action by the parties thereto.
NOW THEREFORE, LREMC hereby agrees to and does join in the Declaration and
agrees to be bound as a Declarant and a Lot Owner (as such terms are defined in the Declaration)
and hereby gives notice and declares that the Property shall be held, transferred, sold and
conveyed subject to the easements and covenants, conditions and restrictions set forth in the
aforesaid Declaration. LREMC further declares, creates and grants unto each owner of a Lot
(including but not limited to the Grantees), for their benefit and their Permittees and their
respective Lot, all of those easements and rights granted by a Declarant and a Lot Owner as more
i
particularly set forth in the Declaration.
(Signature pages follow)

1084
0532
This the I8th day of March, 2014.
BK:01084 PG:0532
LUMBEE RIVER ELECTRIC MEMBERSHIP COPORATION
r r4c[��tt 77 TaSE:SL)
By:
R ge xendr a resident
-. Iei,iger6''
Attest:
erbert Clark, Secretary
NORTH CAROLINA
ROBESON COUNTY
1, a Notary Public for said County and State, certify that Herbert Clark personally
came before me this day and acknowledged that he is Secretary of Lumbee River Electric
Membership Corporation, a North Carolina Electric Cooperative,. and that by authority duly
given and as the act of the corporation, the foregoing instrument was signed in its name by its
President, Roger Oxendine, sealed with its corporate seal, and attested by him as its Secretary.
id and seal this 18th day of March, 2014.
LLv ,
Notary Public

34
0533 BK:01084 PG:0533
LENDER CONSENT TO DECLARATION OF EASEMENTS AND COVENANTS,
CONDITIONS AND RESTRICTIONS FOR STONE GATE VILLAGE
Consent of Lender
United States of America (Rural Utilities Service) and National Rural Utilities
Cooperative Finance Corporation (collectively, "Lender"), holds a security interest in Tract I as
shown on the map entitled "Venture Properties Group, LLC" and recorded in Plat Cabinet 4,
Slide 4-28, Map 4 of the Office -of the Hoke County Registry in the form of a mortgage, as
supplemented, made by Lumbee River Electric Membership Corporation.
IN WITNESS WHEREOF, Lender hereby consents to the above Declaration,
subordinates its Lien to such Declaration and agrees that any foreclosure of the Lien will not
terminate or modify the Declaration or any provisions thereof.
United States of America
By: - (SEAL)
Name: PrashaM V. Patel
Title: trwOtfY.lID ENIMM
CTA ° t National Rural Utilities Cooperative Finance
•' N �} , $f Corporation
By: See riexfi Pa; " J . (SEAL)
r of cod: ' Name:
Title:
STATE OF
COUNTY OF
, Bra@ _ V P e
1, a Notary Public, do hereby certify that
of United States of America, personally appeared be ore me
this day and acknowledged the due execution of the foregoing instrument on behalf of the United
States of America.
Witness my hand and official seal or stamp, this the it day o
2014.
Public
My commission expires:
r4TGVt1'Ptl TTR1Cr0F00LjA.W'
*CMVy"'Exp M�31,7a16

1684
0534 BK:01084 PG:0534
NATIONAL RURAL UTILITIES
COOPERATIVE FINANCE CORPORATION
for itself and as Master Servicer under one
or more servicing agree ents on behalf of
the Federaljgrigl� ral Mortgage
Corporation.
By:
Assistant Secretary -Treasurer
COMMONWEALTH OF VIRGINIA )
SS
COUNTY OF LOUDOUN )
Shmmen Dmiu CboJen
I, , a Notary Public in and for the Commonwealth of Virginia,
County of Loudoun, do certify that Bronson A Byrd whose name is
signed to the writing above, bearing date on the 2PL day of ?914 , has
acknowledged the same before me in my county aforetsai/UA/d.
Given under my hand this ���� day of LVt(.-Al
/VI
(Notarial Seal) otary bli
My commission expires:
SHANNON CENISE CLOUDEN
Notary Public
Commonwealth of Virginia
7501045
My commission Expires Noy 30. 2015
CFC MASTER
AA001-F-000O (JABLONJ)
89584

0839
0519
ar Certl9cate of Appmd for R9todr4
I hereby eertlly that thb transaction
here-cn has been found to eoMly vdth the
Fj!,:ivtsion ReguI00AS of the Ccunty of
Hera, North Carollra, and that thi3 has
been approved fur reeerean� to the C":cs
of the ter oed ht C' ny
O �
ARltOVfdD FOR RFCORSAO
TAX fuPERv:0
Hoke Countv 01-30-2009
NORTH CAROLINA
Rut Fatale
Exaw Tax $700.00
BK:00839 PG:0519
FILED
HOKE COUNTY
ONNIE DUDLEY
REGISTER OF DEEDS
FILED Jan 30, 2009
AT 04:00:07 pm
BOOK 00839
START PAGE 0519
END PAGE 0521
INSTRUMENT # 00596
PfN: 494660001042 Revenue Stamps: $700.00
After recording, please return to: Locklear, Jacobs, Hunt & Brooks PO Box 999 Pembroke, NC 28372
THIS INSTRUMENT WAS PREPARED BY ATTORNEY ARLIE JACOBS/smh
NORTH CAROLINA
HOKE C^OUNTY GENERAL WARRANTY DEED
THIS DEED, made this the 290 day of January, 2009, by and between Lois Hair Long, Widow, hereinafter
termed "Grantor"; and Township Developers, LLC, whose address is 4556 Hwy 72 West, Lumberton, NC 18360,
hereinafter termed "Grantee."
WITNESSETH: DEC 2 0 2013
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns,
and shall include singular, plural, masculine, feminine or neuter as required by context.
That the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is hereby acknowledged,
has and by these presents does grant, bargain, sell and convey unto the Grantee, in the manner and form as described
below, all that certain lot or parcel of land situated in McLauchlin Township, Hoke County, North Carolina, and more
particularly described as follows:
See Attached Schedule "A"
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto
belonging to Grantee in the following manner: Fee simple.
And the Grantor covenant with the Grantee, that Grantor is seized of the premises in fee simple, has the right to
convey the same in fee simple, that title is marketable and free and clear of all encumbrances, and that Grantor will
warrant and defend the title against the lawful claims of all persons whomsoever.
Title to the property hereinafter described is conveyed subject to the following exceptions:
1. All such easements and restrictions that might appear of record or view of the site.
IN WITNESS WHEREOF, the Grantor has hereunto set his hand and seal, or if corporate, has caused this
instrument to be signed in its corporate name by its duly authorized officers and its seal to be hereunto affixed by
authority of its Board of Directors, the day and year first above written.

0839
0520
NORTH CAROLINA
ROBESON COUNTY
BK:00839 PG:0520
Lois Hair Long
1, a Notary Public, do hereby certify that Lois Hair Long personally appeared before me this day and
acknowledged the due execution of the foregoing Deed.
WITNESS my hand and seal this day o 2009.
1
�V Eli '\ Not. ry Public
My Commission e V� d
OTA
s ;
O v
ON CO

0839.
-0521
BK:00839 PG:0521
SCHEDULE"A"
Lying and being in McLauchlin Township, Hoke County, North Carolina, on the south side
of but not adjacent to US Highway No. 401, on the east side of Secondary Road No. 1413,
Bounded on the north by Red Apple Properties, on the south by Treasure Land Development,
Mt. Pisgah Missionary Baptist Church, on the east by Bonnie Young and other lands of Lois
Hair Long, and more particularly described as follows to wit;
Beginning at an iron stake in the eastern right of way line of Secondary Road No. 1413,
said point of beginning being the southwest comer of the land conveyed to Red Apple
Properties in Deed Book 784, page 179, and running thence as the southern line of said
conveyance North 89 degrees 23 min. 59 sec. East 698.22 feet to a pump strainer,
Thence as a line of the land conveyed to Red Apple Properties in Deed Book 784,
page 183, to and with the line of the land convey to Red Apple Properties in Deed Book 784,
page 173, North 89 degrees 28 min. 02 sec. East 869.27 feet to a rebar set,
Thence as a new line South 9 degrees 42 min. 04 sec. East 482.58 feet to an iron rod,
a comer of Bonnie Young,
Thence as the various calls of Bonnie Young the following courses and distances,
South 74 degrees 16 min. 58 sec. West 55.63 feet, South 60 degrees 33 min. 03 sec. West
85.57 feet, South 85 degrees 08 min. 40 sec. West 85.37 feet, South 5 degrees 39 min. 59
sec. East 142.23 feet, South 19 degrees 59 min. 48 sec. West 233.04 feet to a point in Mt
Pisgah Missionary Baptist Church line,
Thence as a line of said property North 82 degrees 31 min. 32 sec. West 610.83 feet
to an iron pipe found,
Thence as a line of Treasure Land Development North 5 degrees 19 min. 54 sec.
West 768.08 feet to an iron pipe found,
Thence as another line of Treasure Land Development South 88 degrees 31 min. 27
sec. West 599.38 feet to an iron pipe found in the eastern right of way line of Secondary
Road No. 1413,
Thence as said right of way line North 18 degrees 07 min. 31 sec. West 61.04 feet to
the beginning containing 16.72 acres more or less

pP.PARry� a
=4.r LIMITED LIABILITY COMPANY
ANNUAL REPORT
Y u.
NAME OF LIMITED LIABILITY COMPANY: Township Developers. LLC
SECRETARY OF STATE' L.L.C. ID NUMBER: 0653967
NA"CURL OP BUSINESS: Reel Estute
REGISTERED AGENT: ,Idavnor, James 11.
KECiIST'13KED OPPICJ?. MAILING ADDRESS: Y.O. Bo.r 11a9
Pembroke. NC 28372
E-Piled Annual Report
-1-0-5588322
Do not data enter manually.
STATE OF INCORPORATION: NC
REGISTERED OFFICE S'CRETT ADDRESS: 763 Conneeh Drive
Pembroke. ANC 28372 Robeson CorotA'
PRINCIPAL OFFICE TELEPHONE NUMBER: 910-521-8013
PRINCIPAL, OFFICE MAILING ADDRESS: Y.O. Box 1149
Pembroke, NC 28372
PRINCIPAL. OFFICE STREET ADDRESS: 763 Comrech Drive
Pembroke. NC 28372
MANAGIiRS/MEMBERS/OI2GANIZIERS:
Name: James If L-Iavnor
,Nome: Moron K7honms
7711c: !Ilonager
7'il1e: ildangt;cr
Iclrlress:
.address:
763 Comrech Drive
763 Comrech Drive
Pembroke, AC 28372
Pembroke, NC 28372
CFRTTFICATTON OF ANNUAL REPORT MUST BE' COMPLET-E) BY ALL LIMITED LIABILITY COMPANIES
James 11 Mavnor
FORM NIIIST RE SIGNED 13Y A NIANAGER/NIENIBER
James 1-1 MaN-nor
06/06/2011
DAAE,
Mana¢er
TYPE OR PRINT NAME TYPO OR PRIN'P'I'1 H-F,
ANNUAL REPORT FEE: S200 MAIL TO: Secretary ul' State • CoTporutions Division • Post Office Box 29525 • Ruler. NC 27626-0525

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Land Resources
James D. Simons, PG, PE Land Quality Section Beverly Eaves Perdue, Governor
Director and State Geologist Dee Freeman, Secretary
March 8, 2012
LETTER OF APPROVAL WITH MODIFICATIONS
Hackett Builders, LLC
Attn: Barry D. Hackett
1152 Kearns -Hackett Road
Pleasant Garden, NC 27303-
RE: Project Name: Stonegate Apartments Acres Approved: 20.75
Project ID: HOKE-2012-039
County: Hoke McLaughlin SR 1413 (Pittman Grove Church Road)
River Basin: Cape Fear Stream Classification: Other
Submitted By: Anderson Engineering & Assoc., P.A.
Date Received by LQS:. 2/13/2012
Plan Type: New
Dear Mr. Hackett:
This office has reviewed the subject erosion and sedimentation control plan. We find the
plan to be acceptable with modifications and hereby issue this letter of Approval With
Modifications. The Modifications Required for Approval are listed on the attached page. This
plan approval shall expire three (3) years following the date of approval, if no land -disturbing
activity has been undertaken, as is required by Title 15A NCAC 413.0129.
Please be advised that Title 15A NCAC 413 .0118(a) requires that a copy of the approved
erosion control plan be on file at the job site. Also, you should consider this letter to give the
Notice required by G.S. 113A-61.1(a) of our right of periodic inspection to insure compliance
with the approved plan.
North Carolina's Sedimentation Pollution Control Program is performance -oriented,
requiring protection of existing natural resources and adjoining properties. If, following the
commencement of this project, it is determined that the erosion and sedimentation control plan is
inadequate to meet the requirements of the Sedimentation Pollution Control Act of 1973 (North
Carolina General Statute 113A-51 through 66), this office may require revisions to the plan and
implementation of the revisions to insure compliance with the Act.
Fayetteville Regional Office 225 Greern Street — Suite 714, Fayetteville, North Carolina 28301
Phone: [phone] / FAX: [phone]-Internet: htto://www.dlr.enr.state.nc.us/pages/landclualitysection.htmi
An Equal Opportunity / Affirmative Action Employer — 50% Recycled / 10% Post Consumer Paper

Letter of Approval with Modifications
Hackett Builders, LLC
March 8, 2012
Page 2 of 3
The developer is responsible for obtaining any and all permits and approvals necessary for the .
development of this project prior to the commencement of this land disturbing activity. This could
include agencies such as the Division of Water Quality's stormwater regulations, their enforcement
requirements within Section 401 of the Clean Water Act, the Environmental Protection Agency and/or
the U.S. Army Corps of Engineers' jurisdiction of Section 404 of the Clean Water Act, the Division of
Solid Waste Management's landfill regulations, local County or Municipalities' ordinances, or others
that may be required. This approval cannot supersede any other permit or approval; however, in the
case of a Cease and Desist Order from the Corps of Engineers, that Order would only apply to wetland
areas. All upland areas would still have to be in compliance with the N.C. Sedimentation Pollution
Control Act.
If any area on site falls within the jurisdiction of Section 401 or 404 of the Clean Water Act, the
developer is responsible for compliance with the requirements of the Division of Water Quality, the
Corps of Engineers and the Environmental Protection Agency (EPA) respectively. Any erosion control
measures that fall within jurisdictional wetland areas must be approved by the aforementioned agencies
prior to installation. The Land Quality Section must be notified of a relocation of the measures in
question to the transition point between the wetlands and the uplands to assure that the migration of
sediment will not occur. If that relocation presents a problem or contradicts any requirements of either
DWQ, the Corps, or the EPA, it is the responsibility of the developer to inform, the Land Quality Section
regional office so that an adequate contingency plan can be made to assure sufficient erosion control
remains on site. Failure to do so will be considered a violation of this approval.
Please be aware that your project will be covered by the enclosed NPDES General
Stormwater Permit NCGO10000 (Construction Activities). You should first become familiar with
all of the requirements for compliance with the enclosed general permit.
Please note that this approval is based in part on the accuracy of the information provided
in the Financial Responsibility Form, which you have provided. You are requested .to file an
amended form if there is any change in the information included on the. form. In addition, it
would be helpful if you notify this office of the proposed starting date for this project. Please
notify us if you plan to have a preconstruction conference
1'
Your cooperation is appreciated.
Sincerely,
/Jodi7�Pacc, EI
Land Quality Section

Letter of Approval with Modifications
Hackett Builders, LLC
March 8, 2012
Page 3 of 3
Enclosures: Certificate of Approval
Modifications Required for Approval
NPDES Permit
Cc: Anderson Engineering & Assoc., P.A. — electronic copy
Robert Harvell, Building Inspector — electronic copy
Belinda Henson, Division of Water Quality
Land Quality Section - Fayetteville Regional Office File
MODIFICATIONS REQUIRED FOR APPROVAL
Project Name: Stonegate Apartments
Project ID: 14OKE-2012-039
County: Hoke
1. Please provide one copy of revised plan: sheets C200, C201, C202, C704. and C705.
I

11 Anderson Engineering & Assoc., P.A.
P.O. Box 1736
305 North Chippewa Street
Lumberton, N.C. 28359
Licensure No.: C-0793
LETTER OF TRANSMITTAL
(Certified Mail No. 7009 2250 0004 2589 4007)
DATE: October 18, 2013
TO: Attn: Larry W. Wade, PE
NCDENR
1612 Mail Service Center
Raleigh, NC 27699-1612
Larry W. Anderson, P.E.
President
PROJECT: Stone Gables Apartments BMP, Hoke Co.
3 el
WE ARE SENDING YOU ®Attached ❑Under separate cover vi
❑Shop Drawings ❑Prints ®Plans
❑Copy of letter El Change Order ❑
a the following items
❑Samples ❑Specifications
COPIES
DATE
NO.
DESCRIPTION
1
11/16/12
Plan Sheet COO — Existing Conditions/Demolition Plan
1
11/16/12
Plan Sheet C100—Overall Site Plan
1
11/16/12
Plan Sheet C203 — Stormwater Management Plan
1
11/16/12
Plan Sheet C704 — Erosion Control Details
1
11/16/12
Plan Sheet C71 I — Stormwater Management Details
THESE ARE TRANSMITTED as checked below:
El For approval
El For your use
®As requested
El For review and comment
❑FOR BIDS DUE
Remarks
Copy To: Project File
❑Approved as submitted
❑Approved as noted
El Returned for corrections
OCR 232013
❑Resubmit _copies for approval
❑Submit_copies for distribution
❑Return _corrected prints
❑Prints returned after loan to us
DEC 2 0 2013
SIGNED: SAMUEL J. POWERS, P.E.
00 National Society of
Professional Engineerso
Phone: [phone] • Fax: [phone] • Email: [e-mail]

i
�f
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 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.
ENR-FRC
1. Project Name Stoneaate Apartments FEB 1 b 2012
2. Location of land -disturbing activity: County Hoke City or Township McLaughlidr—Mop
Highway/Street SR 1413 (Pittman Grove Church Road) Latitude 35.0291890 N Longitude 79.119680 W
3. Approximate date land -disturbing activity will commence: ASAP/January 2012
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.75 Acres
6. Amount of fee enclosed: $ 1365.00 The application fee of $65.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Dino Hackett E-mail Address DHack560aol.com
Telephone [phone] Cell # N/A Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hackett Builders LLC 336.362.2041 336.697.3098
Name Telephone Fax Number
1152 Kearns -Hackett Road 200 D Pomona Drive
Current Mailing Address Current Street Address
Pleasant Garden NC 27303 Greensboro NC 27407
City State Zip City State Zip
10. Deed Book No. 962 Page No. 341 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Hackett Builders LLC [e-mail]
Name E-mail Address
1152 Kearns -Hackett Road 200�Pomona Drive w'�-b
Current Mailing Address Cur fent Street Addre s
Pleasant Garden NC 27303 Greensboro NC 27407
City State Zip City State Zip
Telephone [phone] Fax Number 336.697.3098

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 State Zip
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:
Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax
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.
j' h c>e,pa
�Bina Hackett Owner
Type or print name Title or Authority
Signature Date
I, at cA c a Notary Public of the County of GuoR cY
State of North Carolina, hereby certify that SAAkV p, NAr k4!i f appeared
personally before me this day and being duly worn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 4 day of TAOOAA,y 20
Seal
z n�, A-u-4
Notary
Mycommissionexpires 3�a6/����
L. Allan Leach
Notary Public
Guilford County
North Carolina