NCC230587_FRO Submitted_20230306

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.
Project Name Brookwood Lots 41, 48, 54 and 55
2. Location of land -disturbing activity: County Moore City or Township McNeill Township
Highway/Street Enfield Drive Latitude(decimal degrees) 35.291389 Longitude(decimal degrees)-79.409444
3. Approximate date land -disturbing activity will commence: February 08, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.51 acres
6. Amount of fee enclosed: $ 300.00 . 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. Has an erosion and sediment control plan been filed? Yes ✓ Enclosed ✓ No 71
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Watson Caviness
Phone: Office# 910-339-6330
E-mail Address P1 ),cavinessland.com
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caviness Land Development, Inc.
Name
1041 B Robeson St
Current Mailing Address
Fayetteville NC 28305
City State Zip
910-339-6330 910-237-0572
Phone: Office # Mobile #
1041 B Robeson St
Current Street Address
Fayetteville NC 28305
City State Zip
10. Deed Book No. 5765 Page No. 212 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 parly(ies).
Caviness Land Development, Inc.
Company Name
1041 B Robeson St.
Current Mailing Address
Fayetteville NC 28305
City State Zip
pi(o)-cavinessland.com
E-mail Address
1041 B Robeson St.
Current Street Address
Fayetteville NC 28305
City State Zip
Phone: Office # 910-339-6330 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 of Registered Agent is a company)

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:
Caviness Land Development, Inc. 910-339-6330 910-339-6333
Name Phone: Office # Mobile #
1041 B Robeson St 1041 B Robeson St
Current Mailing Address Current Street Address
Fayetteville NC 28305 Fayetteville _ NC 28305
City State Zip City State Zip
Deed Book No. 5813 Page No. 345 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record.
Name
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
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. -
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.

(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.
Watson Caviness
Type or print namV
Signature
Owner/Manager
Title or Authority
01 /26/2023
Date
I, Lori Simpson Epler , a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Watson Caviness 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 26th day of Janaury 2023
Notary Public Notary
LLari Sirlrpsait Eplor
C.n LANorI' F ;rne Couynty My commission expires 11-14-2024
th Carolina