NCC230813_FRO Submitted_20230327

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
2
3
4
5
6
7
8
Project Name
Waite Family Residence
Location of land -disturbing activity: County Cabarrus
City or Township Concord
Highway/Street Barr Road Latitude 350 27' 17.49" N Longitude 800 41' 20.12" W
Approximate date land -disturbing activity will commence: 06/01 /2023
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.630 acres
Amount of fee enclosed: $ 500.00 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed X No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
Phone: Office #
Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Frederick and Kelly Waite
Name
13502 Long Common Parkway
Current Mailing Address
Huntersville, NC 28078
City
[phone]
Phone: Office # Mobile #
13502 Long Common Parkway
Current Street Address
Huntersville, NC 28078
State Zip City
State
Zip
10. Deed Book No. 13952 Page No. 0278 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Frederick and Kelly Waite
Company Name
13502 Long Common Parkway
Current Mailing Address
Huntersville, NC 28078
[e-mail]
E-mail Address
13502 Long Common Parkway
Current Street Address
Huntersville, NC 28078
City State Zip City State Zip
Phone: Office # 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 (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 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.
Frederick Waite Homeowner
Type or print name
Title or Authority
,2/
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Signature Date
-- — — — ------- — -- --------- ------- — — -------- — ------ — — ----- — - —
aM
a Notary Public of the County of I *C k- A,
State of North Carolina, hereby certify that e —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 /15� day of "r-. a , 2 0
SIOMARA CASTRO
NOTARY PUBLIC Nol'ary'
MECKLEN9003 COUNTY, N.C.
My Commission Expires 12-01-2026 My commission expires

(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.
Frederick Waite
Type or print name
Homeowner
Title or Authority
Signature Date
------------------------------------------------------------------------------------------------------------------------------------
, a Notary Public of the County of
State of North Carolina, hereby certify that 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
Notary
Seal
My commission expires
,20