NCC230629_FRO Submitted_20230321

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 Kings Grant Section E-3 Lots 638, 639, 640, 641, 642, 643 644 645 646 and 646A
2. Location of land -disturbing activity: County Cumberland City or Township Cross Creek Township
Highway/Street Rempstone Ln Latitude(decimai deg)35.141032 Longitude(decimal deg)-78.889318
3. Approximate date land -disturbing activity will commence: January 25, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.26 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Palmer Williams E-mail Address pwilliamsCac-sprop.com
Phone: Office# 910-864-1125 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SRW Builders, LLC
Name
2709 Thorngrove Ctourt
Current Mailing Address
Fayetteville NC 28303
City State Zip
910-864-1125 910-261-7012
Phone: Office # Mobile #
2709 Thorngrove Court
Current Street Address
Fayetteville NC 28303
City State Zip
10. Deed Book No. 5925 Page No. 733 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 proptietorship or if the
landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible pa►fy(ies).
SRW Builders, LLC
Company Name
2709 Thomg ove Court
Current Mailing Address
pwilliams(d)c-sorop.com
E-mail Address
2709 Thornarove Court
Current Street Address
Fayetteville NC _ 28303 Fayetteville NC 28303
City State Zip City State Zip
Phone: Office # 910-864-1125 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
Current Mailing Address
City
Phone: Office #
State Zip
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, 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 attomey-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 or print name
40iganaturee
Owner/Manager
Title or Authority
Date
i, '�QtM KM *- )a Notary Public of the County of Ck wt b& hock
State of North Carolina, hereby certify that Pa(W W u M t( aM- 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
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