NCC223125_FRO Submitted_20220906

FINANCIAL RESPONSIBILITWOWNERSHIP 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1.
2.
3.
4.
5.
6.
7.
8.
Project Name McMillan Manor Subdivision
Location of land -disturbing activity: County Cumberland City or Township Gray's Creek
Highway/Street John McMillan Road Latitude(decimal degrees) 34.8987 Longitude(decimal degrees) 78.8850
Approximate date land -disturbing activity will commence: August 15, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.3 ac
Amount of fee enclosed: $1 ,500.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ben Stout E-mail Address [e-mail]
Phone: Office # 910-779-0019
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lawrence C. Smith & Oleta C. Smith
Name
4944 Grays Creek Church Road
Current Mailing Address
Hope Mills, NC 28348
City State
Phone: Office # Mobile #
4944 Grays Creek Church Road
Current Street Address
Hope Mills, NC 28348
Zip City
State
Zip
10. Deed Book No. 2636 Page No. 551 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible pa►ty(ies).
Stout Land Development, LLC [e-mail]
Company Name E-mail Address
1786 Metromedical Drive 1786 Metromedical Drive
Current Mailing Address
Fayetteville, NC 28304
City State Zip
Phone: Office # 910-779-0019
Current Street Address
Fayetteville, NC 28304
City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
cA
Type or t na:tq
V)
Signature
c.A+Vl
Title or Authority
Date
------------------------------------------------------------------------------------------------------------------------------------
a Notary Public of the County of -�M�58&%
State of North Carolina, hereby certify that /J�h��� appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this q
11�G 4ti
ARY
A
!9,yp&ON CO�
day of Re , 20 Z-,
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Notary
My commission expires to- 6 - ZS

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Lawrence C. Smith & Oleta C. Smith
Name Phone: Office # Mobile #
4944 Grays Creek Church Road 4944 Grays Creek Church Road
Current Mailing Address Current Street Address
Hope Mills, NC 28348 Hope Mills, NC 28348
City State Zip City State Zip
Deed Book No. 7175 Page No. 765 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.