NCC224065_FRO Submitted_20221213

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.
1. Project Name Meadowbrook Subdivision
2. Location of land -disturbing activity: County Pitt
City or Township Grifton
Highway/Street Casey Drive Latitude(decimal degrees) 35.378372 Long itu de(decimal degrees) •77.426903
3. Approximate date land -disturbing activity will commence November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
Residential
16.00 acres
6. Amount of fee enclosed: S 1,600 . 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 ❑ No V
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Barton Horne
E-mail Address [e-mail]
Phone: Office # 252-746-7628 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Town of Grifton 252-7524-5168
Name
PO Box 579
Current Mailing Address
Grifton
City
Phone: Office #
112 W Fire Tower Road
Current Street Address
Mobile #
NC 28530 Grifton NC 28530
State Zip City State Zip
10. Deed Book No. 3263 Page No. 410 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).
Will Kuhn Homes, LLC
Company Name
4226 Dunhagan Road
Current Mailing Address
Greenville NC 27858
City
Phone: Office #
State Zip
[e-mail]
E-mail Address
4226 Dunhagan Road
Current Street Address
Greenville NC 27858
City State Zip
Mobile # [phone]
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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
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.
Will Kuhn
Typ print name
-0
Signature
Owner/Manager
Title or Authority
I ZZ
Date
I, [3 �i a usse t l a Notary Public of the County of I 1 1
State of North Carolina, hereby certify that � I 1 I Okm 0' Mhn M! appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
-aa
Witness my hand and notarial seal, this Z- day of 20
(( K ML Lv� D- p
Oif)a us�li
Seal
My commission expires( i C
FQGINARUSSELI. k�-� NOTARY PUBLIC
Pitt CountyNorth CaralinakLmission ExP'sres

Continued from Items 9 & 90 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:
John D. Sparrow 703-203-4160
Name Phone: Office # Mobile #
4508 Pine Hollow Dr 4508 Pine Hollow Dr
Current Mailing Address Current Street Address
Wilmington NC 28412 Wilmington NC 28412
City State Zip City
Deed Book No. 512 Page No. 130
Landowner 3 of Record:
Faye W. Haddock Trustee
Name
779 Wall Street
Current Mailing Address
Grifton NC
City State
Deed Book No. 3477
Landowner 4 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
779 Wall Street
Current Street Address
28530 Grifton NC 28530
Zip City
Page No. 538
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #