NCC230980_FRO Submitted_20230418

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 NCGO1 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.
1. Project Name Bailey Road Subdivision Phase 2
*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 Martin City or Township Williamston
Bailey Road 35.814 -77.149
Highway/Street Latitude(decimal degrees) LOngltUde(decimai 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): 3.0
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 Ex No Ex
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tonnie Prevatte E-mail Address [e-mail]
Phone: Office# 910-258-5345 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Triangle Developments of Eastern Carolina, Inc. 252-752-8274
Name Phone: Office# Mobile#
802 Recycling Lane
Current Mailing Address Current Street Address
Greenville NC 27834
City State Zip City State Zip
K-17
10. Deed Book No. Page No. 693 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).
CHM Homes, Inc. [e-mail]
Company Name E-mail Address
5000 Clayton Road
Current Mailing Address Current Street Address
Maryville, TN 37804
City State Zip City State Zip
Phone: Office# 865-380-3000 Mobile#
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.
C)(\ksf oX\ � ,
Type or print me Title or Authority
\r2,5
Signature Date
I, N A/rl e,OL Ty �VAAA-oY l , a Notary Public of the County of � 1(�Q
se�e. 1 `� ll
�State of , hereby certify that 0 10A, Qlt appeared personally
before me this day and being duly sworn acknowledged that the above tbrm was executed by him/her.
Witness my hand and notarial seal, thisV)°
day of YQ , , 20 27
LIY\0;33.-X6- 3537—
�.�01►•• , `S0). Not ry
7. • ATE • 0
(1F : _ My commission expires \\ \\\"7,5
Q:TEN` r SSEE c = 11
NOTARY
••.• PU We/
.&

PROPERTY OWNER AUTHORIZATION
Draft Erosion and Sedimentation Control Plan
To Whom It May Concern
I Ed Whitehurst,Jr. Vice President of Triangle Development of Eastern Carolina, Inc. own
property located at latitude 35.814/ longitude-77.149, Martin County, Williamston, NC Bailey
Rd, SUBDIVISION SITE PHASE 2, and I hereby grant my consent for CMH Homes, Inc. to submit
a Draft Erosion and Sedimentation Control Plan and to conduct anticipated land disturbing
activities on said property.
Signature Date
I SQ\r)r) `-),)vrAbn Notary Public of the County of 3E0 U (Z 1
State of North Carolina, hereby certify that Ed Whitehurst, Jr. personally
appeared before me this day and being duly sworn acknowledged the due
execution of the authorization.
Witness my hand and notarial seal, this d rel day of Fe brccarcd , 2023.
Notary
My commission expires(

68943 NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
INVOICE NUMBER INVOICE DATE DESCRIPTION AMOUNT
PERMIT FEE FOR 01/26/2023 RETURN TO PARKER VANCE 300.00
SEDIMENT CONTROL
300.00
CHECK NO.234947 FOR QUESTIONS CALL(865)-380-3936 PLEASE DETACH BEFORE DEPOSITING
THIS CHECK IS PRINTED ON A COLORED BACKGROUND WITH MICROPRINTING IN THE SIGNATURE LINES
CHECK NO. 234947
CMH Homes, Inc.
P.O. Box 9790 CHECK DATE 01/30/2023
SUNTRUST
Maryville TN 37802 SUNTRUST Bank,East I'ennessoe or 64-79/611
(865)-380-3936 SUNTRUST Rank,Northwest Georgia.N.A.
CHECK AMOUNT
PAY Three Hundred Dollars And Zero Cents***** ***********$300.00
TO THE VOID AFTER 180 DAYS
C--"N
ORDER NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY L�, , a ' `"
6216 STONEBRIDGE RD
OF Wilmington NC 28409