NCC230834_FRO Submitted_20230328

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.
Project Name NC HWY 210 TOWNHOMES
Location of land -disturbing activity: County Haft nett
City or Township Lillington
Highway/Street NC Hwy 210 Latltude(decimal degrees05.435847 Longltude(decimal degrees). 8.795928
Approximate date land -disturbing activity will commence: January 2023
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential & Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.0 Acres
6. Amount of fee enclosed: 1,300 . 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 N(
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Stephen Ballentine E-mail Address [e-mail]
Phone: Office # 919-594-1626 x6290 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
KDP Development, LLC
Name
1187 North Raleigh Street
Current Mailing Address
Angier, NC 27501
City State
M.
919-427-8654 919-427-8654
Phone: Office #
1187 North Raleigh Street
Current Street Address
Angier, NC 27501
City State
10. Deed Book No. 4065 Page No. 622
Mobile #
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 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 party(ies).
KDP Development, LLC
Company Name
1187 North Raleigh Street
Current Mailing Address
Angier, NC 27501
City State Zip
Phone: Office # 919-427-8654
[e-mail]
E-mail Address
1187 North Raleigh Street
Current Street Address
Angier, NC 27501
City State Zip
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
eg r �� to� Y g ation should there be an change in the information provided herein.
Type rint name Title or Authority
2 Z
- Sig nature Date
ES coad ' a Notary Public of the County of tk-a'y K t�
State of North Carolina, hereby certify that 4 o) S o Me o-y\(c �ppeared personally V a
before me this day and being duly sworn acknowledged that the above for as executed by him/her.
Witness my hand and notarial seal, this day of �,JbveM-, '?-V
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