NCC230154_FRO Submitted_20230208

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 Jones Creek Meadows
2.
3.
4.
5.
Location of land -disturbing activity: County Harnett City or Township Upper Little River
SR 1235 35.3910 Long ( itude decimal degrees) -78 9495
Highway/Street LatltUde(decimal degrees, g
Approximate date land -disturbing activity will commence:
09-01-2022
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.1
6. 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.
7
L
9
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bradley Stancil
Phone: Office # [phone]
E-mail Address [e-mail]
Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Brad Andrew Salmon & Rebecca Wyhof Salmon
Name
2006 LEE AVE
Current Mailing Address
SANFORD, NC 27330-5750
City State Zip
Phone: Office #
2006 LEE AVE
Mobile #
Current Street Address
SANFORD, NC 27330-5750
City
10. Deed Book No. 3972 Page No. 857
State
Zip
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).
BS Land, LLC
Company Name
466 Stancil Rd.
Current Mailing Address
Angier NC 27501
City State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
466 Stancil Rd.
Current Street Address
Angier NC 27501
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 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)

(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.
Bradley Stancil
Type or rint name
SigFiiKure
Managing Member
Title or Authority
Date
'- L--'q I S-�,c lL W a Notary Public of the County of L i F^ e—
State of North Carolina, hereby certify that .n ✓�� I appeared personally
before me this day and being duly sworn acknowledged fhat the above form was executed by him/her.
Witness my hand and notarial seal, this / a da
r1EAt S+Ta,
0Tq��
• •_ e>
�6LIC
My commission expires / I / I -' "—

Additional Landowners:
Stephen Alexander Salmon & Elisa June Salmon
1661 PEACH FARM RD LILLINGTON, NC 27546-6518
Deed Book 3972, Page 859

NCDEQ-EMLR
225 GREEN STREET, SUITE 714
FAYETTEVILLE, N. C. 28301
Re: Jones Creek Meadows - Owners Consent
To Whom It May Concern:
Stephen Alexander Salmon & Elisa June Salmon hereby authorize BS Land, LLC to
submit an erosion control plan on their behalf and grants permission for land
disturbance and submission for NCDEQ erosion control permit Jones Creek Meadows
Subdivision - NC PIN 0519-47-3666.000
Stephan AleAnder Salmon . Date
'1 ez� - Z 12,
Elisa I& Salmon Date

NCDEQ-EMLR
225 GREEN STREET, SUITE 714
FAYETTEVILLE, N. C. 28301
Re: Jones Creek Meadows - Owners Consent
To Whom It May Concern:
Brad Andrew Salmon & Rebecca Wyhof Salmon hereby authorize BS Land, LLC to
submit an erosion control plan on their behalf and grants permission for land
diggbance and submi ion for NCDEQ erosion control permit Jones Creek Meadows
Sdbdivis�n 4NC PIN/519-47-3666.000
Wyhof SAImW `Date