NCC224165_FRO Submitted_20230104

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 NIA in the blank.)
Part A.
1 _ Project Name Joseph and Lisa Horner Homesite
2 Location of land -disturbing activity County Burke City or Township Morganton
Highway/Street Mountain Vista Drive Latitude)deamat degrees) 35.721 Longltudeldeamai degrees) 81 -6035
3. Approximate date land -disturbing activity wid commence After -The -Fact Plan
4
5
6.
7.
Purpose of development (residential, commercial. industria institutional etc ) Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas)' 4.3 Acres
Amount of fee enclosed $ 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 ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joseph Horner E-mail Address Iisahorner46@gmail. corn
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Joseph and Lisa Horner
Name
52 Olson Road
Current Mailing Address
New Waverly, TX 77358
Phone. Of ice #
832-484-2647
Mobile #
3752 Mountain Vista Drive
Current Street Address
Morganton, NC 28655
City State Zip City State Zip
10 Deed Book No. 2625 Page No 749 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 names) of the owner(s) may be listed as the financially responsible party(ies).
Joseph and Lisa Horner
Company Name
52 Olson Road
Current Mailing Address
New Waverly, TX 77358
City State Zip
Phone. Office #
[e-mail]
E-mail Address
3752 Mountain Vista Drive
Current Street Address
Morganton, NC 28655
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
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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:
Joseph Horner
Name of Registered Agent
52 Olson Road
Current Mailing Address
New Waverly, TX 77358
City State Zip
Phone: Office #
[e-mail]
E-mail Address
3752 Mountain Vista Drive
Current Street Address
Morganton, NC 28655
City State Zip
Mobile # [phone]
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.
NIA
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.
Joseph Horner
Property Owner
Typ print name Title or Authority
8126/22
Sifnature Date
I, LLL1� 1) (&JA a Notary Public of the County of Ge-
state of North Carolina, hereby certify that 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 day of Lls7 20
k2
,`,�11i1111rf��
ot
IN "Y. Nat ry
= m : �•+ P -
= My commission expires -
'U .

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.
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 3 of Record.
NIA
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.
NIA
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.
NIA
Name
Current Mailing Address
Phone. Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No Provide a copy of the most current deed.

Continued from Item 7 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.
NIA
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone Office # Mobile #
NIA
Company 3 Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
NIA
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone Office # Mobile #
NIA
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #