NCC231166_FRO Submitted (2)_20230425

NT# 22079
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. Project Name Lake Tabor Estates Lot Clearing / Grading
2. Location of land disturbing activity: County Columbus City or Township Tabor City
Ten Mile Road(SR 1308) 34.17 Lon ItUde decimal degrees)-78.85
Highway/Street Latitudeoecimal degrees) g (
3. Approximate date land-disturbing activity will commence: April 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): 29.90
6. Amount of fee enclosed: $3,000.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Phone: Office# 910-287-5900 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Lake Tabor Estates Development Group 910-653-7770 910-641-7731
Name Phone: Office# Mobile#
P.O. Box 35 905 Pireway Road
Current Mailing Address Current Street Address
Tabor City NC 28463 Tabor City NC 28463
City State Zip City State Zip
513/1314/1314 164/142/145
10. Deed Book No. Page No. 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).
Lake Tabor Estates Development Group bill.phippslaw©gmail.corn
Company Name E-mail Address
P.O. Box 35 905 Pireway Rd.
Current Mailing Address Current Street Address
Tabor City, NC 28463 Tabor City, NC 28463
City State Zip City State Zip
Phone: Office# 910-653-7770 Mobile# 9 S1:0f6E7ax 910-641-7731
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.
Lake Tabor Estates Development Group
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.
William W. Phipps Partner
ype or print name Title or Authority
\
ICQ,�'VL �� iL.y 3/11/20aOA3
Signature /i Date
I, M Q 1�s 1l l ( ) , a Notary Public of the County of Columbus
State of North Carolina, herebycertify that William W. Phipps, Partner appeared Y 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 1 1th day of March 2023
tiE gA M. f;
•;<>' /��� t Notary
Seal NOTARY PUBLIC My commission expires Q )
f - o`07),
COLUMBUS
COUNTY44,

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
PARTNERS IN LAKE TABOR ESTATES DEVELOPMENT GROUP:
William Winslow Phipps [e-mail]
CUrnpdny"2'-htame E-mail Address
105 Creekwood Lane 105 Creekwood Lane
Current Mailing Address Current Street Address
Tabor City NC 28463 Tabor City NC 28463
City State Zip City State Zip
Phone: Office# 910-653-7770 Mobile# [phone]
Kyle A. Cox [e-mail]
Gotrrpatty-e-f+arte E-mail Address
203 Canal Street 203 Canal Street
Current Mailing Address Current Street Address
Tabor City NC 28463 Tabor City NC 28463
City State Zip City State Zip
Phone: Office# 910-641-1515 Mobile# [phone]
Jonathan Kyle Cox [e-mail]
Gempaay,4-Nate E-mail Address
102 Miriam Lane 102 Miriam Lane
Current Mailing Address Current Street Address
Tabor City NC 28463 Tabor City NC 28463
City State Zip City State Zip
Phone: Office# 910-640-2900 Mobile# [phone]
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#