NCC222700_FRO Submitted_20220802

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.
1. Project Name Nelsons Farm - Phase 2
2. Location of land -disturbing activity: County Harnett City or Township Lillington
Highway/Street 0IdUS421 Latitude 35.39638 Longitude-78.83917
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.5 ac
6. Amount of fee enclosed: $ 2,700.00 . The application fee of $1oo.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is goo ).
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
Joe Conlan E-mail Address [e-mail]
Telephone [phone] Cell 4 269-547-3807 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mattamy Homes LLC 269-547-3807
Name Telephone Fax Number
11000 Regency Pkwy - Suite 110 11000 Regency Pkwy - Suite 110
Current Mailing Address Current Street Address
Cary NC 27518 Cary NC 27518
City State Zip City State Zip
10. Deed Book No. 4066 Page No. 0787 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.
Joseph Conlan c/o Mattamy Homes [e-mail]
Name
11000 Regency Parkway, Suite 110
E-mail Address
11000 Regency Parkway, Suite 110
Current Mailing Address Current Street Address
Cary NC 27518 Cary NC 27518
City
State Zip City
State
Zip

Telephone [phone] Fax Number
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A 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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address
N/A
Current Street Address
N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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 attomey-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.
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Type or print name Title or Authority
Sign re Date
I, Ai x /5 v aez_ , a Notary Public of the County of W-gxx~
State of North Carolina, hereby certify that 60"it'O^f 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
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