NCC222841_FRO Submitted_20220810

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.
1. Project Name Glenhurst
2. Location of land -disturbing activity: County Union City or Township Indian Trail
Highway/Street Potters Road Latitude 35.051278 Longitude-80.701598
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):43.57 Acres
6. Amount of fee enclosed: $ 2,860.00 . 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 Ron Willinci E-mail Address willincirea-stanleymartin.com
Telephone [phone] Cell # Fax # N/A
9. Landowner(s) of Record:
Stanley Martin Homes, LLC
Name
820 Forest Point Circle, Suite 100
Current Mailing Address
704.808.1132
Telephone
N/A
Current Street Address
Charlotte NC 28273 N
City State Zip City
N/A
Fax Number
State Zip
10. Deed Book No. 8401 Page No. 734-739 Provide a copy of the most current
deed.
Part B.
1. 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):
Stanley Martin Homes willinareastanleymartin.com
Name E-mail Address
820 Forest Point Circle, Suite 100 N/A
Current Mailing Address Current Street Address
Charlotte, NC 28273 N/A
City State Zip City State
Zip
Telephone [phone] Fax Number N/A

Gerald R. Thomas
Name
516 Raintree Drive
Current Mailing Address
N/A
Telephone Fax Number
_6834 Potter Road
Current Street Address
Matthews NC 28104 Matthews NC 28104
City State Zip City State Zip
Deed Book No. 3328 Page No. 400 Provide a copy of the most current deed.
Potter's Creek Homeowners Association, Inc. N/A
Name Telephone Fax Number
10800 Sikes Place Suite 105 0 Potter Cove
Current Mailing Address Current Street Address
Charlotte NC 28277 Weddington NC 28277_
City State Zip City State Zip
Deed Book No. 5576 Page No. 283 Provide a copy of the most current deed.
Wendy Steele Swenson and Robert Sink Swenson N/A
Name Telephone Fax Number
6846 Potter Road 6846 Potter Road
Current Mailing Address Current Street Address
Matthews NC 28104 Matthews NC 28104
City State Zip City State Zip
Deed Book No. 0765
Page No. 555
Louis Payeur and Jennifer Obrien Payeur _
Name Telephone
Provide a copy of the most current deed.
1142 Carole Court _ 1142 Carole Court
Current Mailing Address Current Street Address
N/A
Fax Number
Matthews NC 28104 Matthews NC 28104
City State Zip City State Zip
Deed Book No. 7727 Page No. 459 Provide a copy of the most current deed.

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:
NIA
Name E-mail Address
Current Mailing Address
Current Street Address
Indian Trail/ Union County
City State Zip City
Telephone
Fax Number
State Zip
(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:
CT Corporation Svstem
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City
State Zip City
Telephone [phone]
Fax Number
State Zip
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.
Type or print name Title or Authority
7/0 L74
Signature Date
I, CDVOVIL��, a NotaryPublic of the County of
State of North Carolina, hereby certify that V i Ar� app ared
personally before me this day and being duly sworn acknovOedged that the above form was
executed by him.
Witness my hand and notarial seal, this
F
ney B Hefner
ARYPUBLIC
Snburg County
rth Carolina
xpires October 25, 2025
!�_day of
Notary
My commission expires,(-F)11�,.5,}`�