NCC222736_FRO Submitted_20220801

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. Carriage Hill
1. Project Name
2. Location of land -disturbing activity: CountyMoore City or Township Carthage
Highway/Street
Pinehurst Ave Latitude36.122 Longitude -79.526
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste area
13.50 AC
910.00 . The application fee of $65.00 per acre rounded
6. Amount of fee enclosed: $ pp p (
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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Colin Webster E-mail Address [e-mail]
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Grosvenor Land LLC
Name Telephone Fax Number
PO Box 1872 30 Country Club Blvd
Current Mailing Address Current Street Address
Southern Pines, NC 28388-1872 Whispering Pines, NC 28327-9377
City State Zip City State Zip
10. Deed Book No.5619 Page No.166 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Grosvenor Land, LLC [e-mail]
Name E-mail Address
PO Box 1872 30 Country Club Blvd.
Current Mailing Address Current Street Address
Southern Pines, NC 28388 Whispering Pines, NC 28327
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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
Cu` , t Mailing Address Current StreerAddress
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.
Colin Webster for Grosvenor Land
Type or print name '
° Signature
Manager
Title or Authority
1-24-2022
Date
�t5�� �iC,)'��i�l 'a Notary Public of the County of X1 D�
State of North Carolina, hereby certify that (Zp /�1�1 �� L11 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my h C ' otarial seal, this �! day �i4 20
E�os�9
FE8.03,2028 Notary
Seal %
'• • s
My commission expire