NCC223118_FRO Submitted_20220908

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
Project Name Trinity Church Rd. Mass Grading
2. Location of land -disturbing activity: County Cabarrus City or Township Kannagolis
Highway/Street Stonewood View Latitude(decimai degrees)35.452203Longitude(decimal degrees)-80.670657
3. Approximate date land -disturbing activity will commence: October 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Borrow Site
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.1
6. Amount of fee enclosed: $ 500 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed Cl No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Autry Dawsey E-mail Address ad( -dnet.net
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Lots and Land Inc.
Name
1520 Candlewyck Court
Current Mailing Address
[phone]
Phone: Office #
1520 Candlewyck Court
Current Street Address
Mobile #
Kannagolis NC 28081 Kannagolis NC 28081
City State Zip City State Zip
10. Deed Book No. 12971 Page No. 126 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 party(ies).
Carolina Lots and Land Inc.
Company Name
1520 Candlewyck Court
Current Mailing Address
[e-mail]
E-mail Address
1520 Candlewyck Court
Current Street Address
Kannapolis NC 28081 Kannapolis NC 28081
City State Zip City State Zip
Phone: Office # [phone] 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:
E. Autry Dawsey Jr.
Name of Registered Agent
1520 Candlewyck Court
Current Mailing Address
ad a(_dnet.net
E-mail Address
1520 Candlewyck Court
Current Street Address
Kannapolis NC 28081 Kannapolis NC 28081
City State Zip City State Zip
Phone: Office # [phone] 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. / J
/Oyjam
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.
E Autry Dawsey Jr.
Type or print name
!✓
President
Title or Authority
Date
a Notary Public of the County of Gc5�
State of North Carolina, hereby certify that 1E. 44 y'+wr, appeared personally
before me this day and being duly sworn acknowledged fKat the ab a form was executed by him/her.
Witness my hand and notarial seal, this day of 20�
SHARLENE CARPENTER
Notary Public, North Carolina
Ga`ifdha County
My Co� Expires My commission expires �ii