NCC230983_FRO Submitted_20230405

FINANCIAL RESPONSISILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 1119202/
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.
1. Project Name Downtown Wesley Chapel
2. Location of land-disturbing activity: County Union City or Township Wesley Chapel
Hi hwa (Street Wesley Chapel Road Latitude 35.00972 Longitude -80.67284
g Y
3. Approximate date land-disturbing activity will commence: 05/01/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):1 .61 acres
6. Amount of fee enclosed: $ 200 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000,00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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 Tom Crouch E-mail Address [e-mail]
Telephone [phone] Cell#
Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Downtown Wesley Chapel, LLC 704-882-1700
Name Telephone Fax Number
231 Post Office Drive, Suite B-8 231 Post Office Drive, Suite B-8
Current Mailing Address Current Street Address
Indian Trail NC 28079 Indian Trail NC 28079
City State Zip City State Zip
10. Deed Book No. 5412 Page No. 345 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Downtown Wesley Chapel, LLC [e-mail]
Name E-mail Address
231 Post Office Drive, Suite B-8 231 Post Office Drive, Suite B-8
Current Mailing Address Current Street Address
Indian Trail NC 28079 Indian Trail NC 28079
City State Zip City State Zip
Telephone [phone] Fax Number

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 State Zip
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:
Dennis W Moser [e-mail]
Name of Registered Agent E-mail Address
231 Post Office Drive, Suite B-8 231 Post Office Drive, Suite B-8
Current Mailing Address Current Street Address
Indian Trail NC 28079 Indian Trail NC 28079
City State Zip City State Zip
Telephone[phone] Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) Telephone Fax Number
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.
Dennis M + r Member manager
TypAorn a e Title or Authority
Sig bate
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a Notary Public of the County of
State of North Carolina, hereby certify that j j appeared personally
before me this day and being duly sworn ac owledged that the above form was executed by him.
Witness my hand and notarial seal, this ` day of z 20
RAENAE H. LITTLE !!�
NOTARY PUBLIC Nota
gly County
North Carolina My commission expires ` `e/D ZO 07
My Commission Expires April 16, 2027