NCC230710_FRO Submitted_20230320

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. Baylor Grove
1. Project Name
2. Location of land -disturbing activity:, County Union City or Township Monroe
Highway/Street Hwy 601 Latitude34.82564 Longitude-80.42381
3. Approximate date land -disturbing activity will commence: 06101 /2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.9 3 AC
6. 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 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Cameron Helms E-mail Address [e-mail]
Telephone [phone] cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
601 South Properties, LLC 704-684-3377 nls
Name Telephone Fax Number
PO Box 2758 3932 Smith Farm Road
Current Mailing Address Current Street Address
Indian Trial, NC 28079 Indian Trail, NC 28079
City State Zip City State Zip
10. Deed Book No, 8411 Page No.124 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
601 South Properties, LLC [e-mail]
Name E-mail Address
PO Box 2758 3932 Smith Farm Road
Current Mailing Address Current Street Address
Indian Trial, NC 28079 Indian Trail, NC 28079
City State Zip City State Zip
Telephone [phone] Fax Number n/a

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Jeremy Harvey jerem camerons-inc.com
Name of Registered Agent E-mail Address
3932 Smith Farm Road 3932 Smith Farm Road
Current Mailing Address
Matthews, NC 28104
City State Zip
Telephone [phone]
Current Street Address
Matthews
City
Fax Number
State Zip
NC 28104
State Zip
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Cameron Helms
Type or print name
Signature
Manager
Title or Authority
Cate
I, 1 ts, 1i TAIYA -,a Notary Public of the County of n
State of North Carolina, hereby certify that*yswo)r��!�IedgeM
appeared
personally before me this day and being dthe above form was
executed by him.
Witness my hand and notarial seal, this CXV day of DcAnbey 20 oCo�
Hale�� ardin Notary
NOTA I P LIC
Union County My commission expires
North Carotina
My Comm. Expires November 7, 2026