NCC223172_FRO Submitted_20220913

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 HEADWATERS APARTMENTS & COTTAGES FPENDE-2018-021 PERMIT MOD.1
2. Location of land -disturbing activity: County_Pender City or Township_Topsail - Hampstead
Highway/Street US 17 and Hughes Rd Latltude(decimal degrees) 34.3585 Longltude(decimal degrees)_ 77.7154
3. Approximate date land -disturbing activity will commence: July 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_
37ac r22.6 ac Approvedl Remainder = 14 ac
6. Amount of fee enclosed: $ 14 ac x $100.00 = $1400.00 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.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris
Email: chris.fay(a-)evolvecos.com
Address 806 Green Valley Road, Suite 311 Telephone [phone]
Cell # same Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Headwaters Properties, LLC
Name
1131-B Military Cutoff Road
Current Mailing Address
Wilmington NC 28405
City State Zip
910-239-5580
Phone: Office #
1131-B Military Cutoff Road
Current Street Address
Mobile #
Wilmington NC 28405
City State Zip
10. Deed Book No._4776 Page No. 627-630
Provide a copy of the most current deed.
Deed Book No._2059 Page No. 2061
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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Hawthorne Headwaters Apartments, LLC 336-544-6205
Name Telephone Fax Number
806 Green Valley Rd, Suite 311
Current Mailing Address Current Street Address
Greensboro NC 27408
City State Zip City State Zip
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)

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
Three Oaks Partners, LLC 910-239-5580
Name Phone: Office # Mobile #
1131-B Military Cutoff Road 1131-B Military Cutoff Road
Current Mailing Address Current Street Address
Wilmington NC 28405 Wilmington NC 28405
City State Zip City State Zip
Deed Book No. 4776 Page No. 630 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State 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 Zip City State 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 Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

(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.
at
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 au ority to execute instruments for the Financially Responsible Party). I agree to provide
corregfeo inform i n should there be any change in the information provided herein.
Typi pri t n e Title or Auth ity
G/r7/ZiLL
Sig t e Date
a Notary Public of the County of N)AJ WOV tr
State of North Carolina, hereby certify thaty-. 6w� W\�5ktA 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 i day of , 20 �D-
Notary
My commission expires
Ae\, S• 8UC.-