NCC231125_FRO Submitted_20230426

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 Green Acres Offsite Sewer
2. Location of land-disturbing activity: CountyCabarruS City or Township Mt. Pleasant
NC Hwy 73 35.416361 -80.484668
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:December 2022
4. Purpose of development (residential, commercial, industrial, instiiutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.21
6. Amount of fee enclosed: $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 x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameJoseph Burleson E-mail [e-mail]
Phone: Office# 704-791-6253 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
CBS Development Group, LLC 704-791-6253
Name Phone: Office# Mobile#
248 Market Street 248 Market Street
Current Mailing Address Current Street Address
Locust NC 28097 Locust NC 28097
City State Zip City State Zip
10. Deed Book No. 1 6083 Page No. 031 1 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).
CBS Development Group, LLC [e-mail]
Company Name E-mail Address
248 Market Street 248 Market Street
Current Mailing Address Current Street Address
Locust NC 28097 Locust NC 28097
City State Zip City State Zip
Phone: Office# 704-791-6253 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:
Joseph Burleson [e-mail]
Name of Registered Agent E-mail Address
248 Market Street 248 Market Street
Current Mailing Address Current Street Address
Locust NC 28097 Locust NC 28097
City State Zip City State Zip
Phone: Office# 704-791-6253 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:
Joseph Burleson [e-mail]
Name of Registered Agent E-mail Address
248 Market Street 248 Market Street
Current Mailing Address Current Street Address
Locust NC 28097 Locust NC 28097
City State Zip City State Zip
Phone: Office# 704-791-6253 Mobile#
Name of Individual to Contact(if Registered Agent is a company)

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.
Landowner 2 of Record:
Cabarrus County
Name Phone: Office# Mobile#
PO BOX 707 466 Walker Rd
Current Mailing Address Current Street Address
Concord NC 28206 Mt Pleasant NC 28124
City State Zip City State Zip
Deed Book No.1 1748 Page No.281 Provide a copy of the most current deed.
Landowner 3 of Record:
Cabarrus County
Name Phone: Office# Mobile#
PO BOX 707 700 Walker Rd
Current Mailing Address Current Street Address
Concord NC 28206 Mt Pleasant NC 28124
City State Zip City State Zip
Deed Book No.4015 Page No.181 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.

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
(d) If 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:
American Engineering [e-mail]
Engineering firm or other consultant E-mail Address
Tom Platt, PE 704-375-2438 980-229-8625
Individual contact person (type or print) Phone: Office# Mobile#
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.
Joseph Burleson
Type or print name Title or Autho ty
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Signatt Date
I, {)--)1'r,n c , a Notary Public of the County of n
State of North Carolina, hereby certify that Use. h Our]P � appeared personally
before me this day and being duly sworn acknowledgbd that the above form was executed by him/her.
Witness my hand and notarial seal, this O day of IN o�Jemho , 20 6
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