NCC230386_FRO Submitted_20230213

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Brookhaven Subdivision - Lots 1,2,3,4,5,6,7,8,9,23,24,25,26,27,28,29,30 & 31
2. Location of land -disturbing activity: Count yFranklln City or Township Dunn Township
Brookhaven Drive 35 89450" �, 78.21261 ` W
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land -disturbing activity will commence. December 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.)- Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.33 ac Q
6. Amount of fee enclosed `P2,800 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. 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 David Edwards E-mail Address [e-mail]
Phone: Office # 919-556-4700 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Red Wells, LLC n/a
11JUMU
PO BOX 610
Current Mailing Address
Youngsville NC
City State
10. Deed Book No. 2274
n/a
Phone: Office # Mobile #
n/a
Current Street Address
27596 n/a
Zip City
Page No. 1797-1799
n/a
State
n/a
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).
Winslow Grand, LLC
Company Name
PO BOX 610
Current Mailing Address
Youngsville
NC 27596
[e-mail]
E-mail Address
140 East Main Street
Current Street Address
Same
City State Zip City State Zip
Phone: Office # 919-556-4700 Mobile # n/a
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
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
(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
(d) If 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:
FLM Engineering, Inc
Engineering firm or other consultant
Christopher Lewis, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
919-610-1051 919-802-7146
Phone: Office # Mobile #
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.
[f�nsit] 1.2 "1
Type or print name Title or Authorit
Si ature Date
-------------------------------------------------------------------------------------------_------ _ __-_--___--__—_--------------
1, L a Notary Public of the County of —*A 11
�1
State of North Carolina, hereby certify that c 1�_LZ)iiJb4z),� 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 )'*10A
TERESA C SMITH
} NOTARY PUBLIC
r1 ` FRANKLIN COUNTY
STATE OF NORTH CAROLINA
20_??
Notary
My commission expires C1012WIG

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.
Landowner 2 of Record
Winslow Custom Homes, LLC n/a n/a
Name Phone: Office # Mobile #
PO BOX 610 n/a
Current Mailing Address Current Street Address
Youngsville NC 27596 n/a
City State Zip City State Zip
226-227 &
Deed Book No.2302 & 2308 Page No. 1512-1513 Provide a copy of the most current deed.
Landowner 3 of Record
Name
Current Mailing Address
City
Deed Book No.`
Landowner 4 of Record
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No
Landowner 5 of Record
Name
Current Mailing Address
City
Deed Book No
Current Street Address
State Zip City State Zip
Page No. 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.