NCC230371_FRO Submitted_20230209

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Name212 Scott Ridge Drive
'If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
1 Location of land -disturbing activity: CountyChatham City or TownshipPlttsboro
Highway/Street Scott Ridge Drive Latitude(decimal degrees)35.816 Longltude(deemal degrees) -79 125
3. Approximate date land -disturbing activity will commence:02-0 ! -2023
4.
5.
6.
7.
8.
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas):3.95
Amount of fee enclosed: $400 . 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 ❑ No 0
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Doug Lawrie E-mail [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Shenandoah Homes 984-200-5540
Name
3724 National Dr., Suite 215
Current Mailing Address
Raleigh NC 27612
Phone: Office # Mobile #
3724 National Dr., Suite 215
Current Street Address
Raleigh NC 27612
City State Zip City State Zip
10. Deed Book No. 2314 Page No. 439 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 lndlvidual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Shenandoah Homes
Company Name E-mail Address
3724 National Dr, Suite 215 3724 National .Dr, Suite 215
Current Mailing Address Current Street Address
Raleigh, NC 27812 Raleigh, NC 27612
City State Tip City State Zip
Phone: Office # 984-200-5540 Mobile #
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
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)

(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, br other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DSA 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.
Type ,print nam Title or Authority
Signa ure _ - Date
I, a Notary Public of the County of
State of North Carolina, hereby certify that. bf, s ll�%,°s appeared personally
before me this day and being duty sworn acknowledged that tl'ie above form was executed by him/her.
Witness my hand and notarial seal, this `OVA day of � 20 ?r3
°I1°I511119111)PIPOy
No ary
�A s My commission expires
N
_ DIARY e T
PUB1,IC
�•f5 1111!!!i!\ti�1

BK 2314 PG 0439
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $500.00
Parcel Identifier No. out of 0001831
Verified by County on the day of 120 By:
Mail/Box to: Grantee
This instrument was prepared by: City of Oaks Law
Brief description for the Index: Lot E Minor Sub
Scott Lawrence
THIS DEED made this 8th day of July 2022 , by and between
GRANTOR I GRANTEE
Courtney Scott Lawrence and spouse,
Jack Turner Lawrence, III
1980 Andrews Store Road,
Pittsboro, NC 27312
FILED ELECTRONICALLY
CHATHAM COUNTY NC
LUNDAY A. RIGGSBEE
REGISTER OF DEEDS
----------------------
----------------------
FILED Jul 08, 2022
AT 03:26:06 PM
BOOK 02314
START PAGE 0439
END PAGE 0440
INSTRUMENT # 08344
EXCISE TAX $500.00
Shenandoah Homes, LLC,
a North Carolina limited liability company
3724 National Drive, Suite 215,
Raleigh, NC 27612
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and shall include
singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is hereby acknowledged, has
and by these presents does grant, bargain, sell and convey unto the Grantee in fee simple, all that certain lot, parcel of land or
condominium unit situated in the City of Baldwin Township, Chatham County, North Carolina and more
particularly described as follows:
BEING all of Lot E as depicted on the plat entitled "Minor Subdivision Survey, Courtney Scott
Lawrence" dated February 8, 2021 and recorded in Plat Book 2022, Page 114, Chatham County
Public Registry.
Property Address: Lot E - Andrews Store Road, Pittsboro, North Carolina 27312
The property hereinabove described was acquired by Grantor by instrument recorded in Book 1846 Page 932
All or a portion of the property herein conveyed =includes or� does not include the primary residence of a Grantor.
A map showing the above described property is recorded in Map Book 2022 Page 114
Submitted electronicallv by Jonathan W Anderson Law in compliance with North Carolina statutes uovernine recordable
documents and the terms of the submitter aereement with the Chatham Countv Resister of Deeds.

BK 2314 PG 0440
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to the Grantee in
fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has the right to convey the same in fee
simple, that title is marketable and free and clear of all encumbrances, and that Grantor will warrant and defend the title against the
lawful claims of all persons whomsoever, other than the following exceptions:
Ad valorem taxes for the current year; utility easements and unviolated covenants, conditions or restrictions that do not materially
affect the value of the property
IN WITNESS WHEREOF, the Grantor has duly executed the foregoing as of the day and year first above written.
�= "�-�" ' 1 � (SEAL)
(SEAL)
Courtney Scoit Lawrence ack Turner Lawrence, III
kle-I no 0 � rrstz•
North Carolina L C;ri=� =Wake
and State aforesaid, certify that
personally appeared before me this day and
in expressed. Witness my hand and Notarial stamp or
seal mis [/C oay or i uiv
I, the undersigned Notary Public of the County or City of L.J ►ky--? and State aforesaid, certify that
Jack Turner Lawrence, III personally appeared before me this day and
acknowledged the due execution of the foregoing instrument for the purposes therein expressed. Witness my hand and Notarial stamp or
seal this vr� day of July 2022.
ENDER
My Commission Expires: D OBI L1 �-� omniiss�o '9i1, �ArJOh Notary Public
(Affix Seal) ;�2?G•.�� = Notary's Printed or Typed Name
NOT4Ry
_ q w
4 202.1 ,C ,
c0UNT��•