NCC230822_FRO Submitted_20230328

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Ridgewood Place Subdivision - SFD Construction - Group 1
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County Forsyth City or Township Winston Salem
Ridgeback Dr. 36.0714-80.1721
Highway/Street _ LatltUde(decimal degrees) LongltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence:4/1 /2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):5.67
6. Amount of fee enclosed: $600 . 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 ❑x Enclosed ❑ No ❑
r;1
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameAndrew Fulcher E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Williams Development Group 336-529-6927
10
Name
Dixon Pitt
Current Mailing Address
331 High Street
336-978-9009
Phone: Office # Mobile #
331 High Street
Current Street Address
Winston Salem, NC 27101
City State Zip City
Deed Book No. RE 2961 Page No.130-139
State
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 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).
True Homes LLC [e-mail]
Company Name
2649 Brekonridge Centre Dr.
Current Mailing Address
Monroe, NC 28110
E-mail Address
2649 Brekonridge Centre Dr.
Current Street Address
Monroe, NC 28110
City State Zip City
Phone: Office # 704-238-1229 Mobile #
State
Zip
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 ufAssumed Name.
Company DBAName
The above information k5true and correct tothe best ofO)yknowledge 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 attorDey-iD-fact, o[ifnot aO iOdiYidUg|, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected information should there be any change iDthe information provided herein.
Brian McWhirter Market Partner Field
Type or printOanle - Title or Authority
3/10/2023 - -- '
|. aNotary Public ofthe County of
State ofNorth Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed byhi0/her.
Witness my hand and notarial seal, this /Op —day of 1W O*rJn
Rosa Whfte
NOTARY PUBLIC Notdy
Setnion County
rth Carolina
My Commission Expires April 8,20]24 My commission '

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.
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.
Landowner 3 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.
Landowner 4 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.
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.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 3 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
State Zip
State Zip
State Zip
City State Zip City State Zip
Phone: Office # Mobile #