NCC224066_FRO Submitted_20221213

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FINANCIAL RESPONSIBILITYIOWNERSHIP FORM NOV 15 2022 I
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007 ��--�
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 NIA in the blank.)
Part A. 1. Project NameGander Lake Phase 7 (Lots)
2. Location of land -disturbing activity: County Wayne City or Township Princeton
Highway/Street Princeton -Pikeville Rd. Latitude 35.4868 Longitude—78.1121
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.,._
5. Total acreage disturbed or uncovered (including off -site borrow and wa to areas): 22.52 Ac.
3 5
6. Amount of fee enclosed: $ . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Varnell E-mail Address [e-mail]
Telephone [phone] Cell # 252-382-0012 1'ax # 252-459-8197
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gander Lake Development, LLC 919-550-7711 NIA
Name Telephone Fax Number
5212 Hwy 70 BUS West 5212 Hwy 70 BUS West
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
10. Deed Book No. 3622 Page No. 715 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.
RRT Development, LLC [e-mail]
Name
5212 Hwy 70 BUS West
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone [phone]
E-mail Address
5212 Hwy 70 BUS West
Current Street Address
Clayton NC 27520
City State Zip
Fax Number NIA

1I 1 r73
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Stocks Engineering [e-mail]
Engineering Firm or other consultant E-mail Address
Kevin Varnell 252-459-8196 252-459-8197
Individual contact person (type or print) Telephone Fax Number
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
Signs
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Title or Authority 1
Date
9-a7-Oa
a Notary Public of the County of j 011JA1i1
State of North Carolina, hereby certify that AV fi i 4al-cry appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness r'" Mt eftip4otarial seal, this day of rvQf , 20Na
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NotaryTA
Seal 161
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