NCC231576_FRO Submitted_20230526

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 N/A in the blank.)
Part A.
1. Project Name Chapel Pines Subdivision
2. Location of land-disturbing activity: County Davidson City or Township Boone
Highway/Street Old Wesley Chapel Road Latitude 35.76965 Longitude -80.3642
3. Approximate date land-disturbing activity will commence: November, 2019
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13.6 AC
6. Amount of fee enclosed: $2,910.00 The Express Permitting application fee is a dual charge. The
normal fee of $65.00 per acre (rounded up to the next 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$2,585).
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 Tim Ragan E-mail Address traqanlexcominc.net
Telephone Cell# [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Piedmont Hardwood Lumber Company, Inc.
Name Telephone Fax Number
PO Box 535
Current Mailing Address Current Street Address
Mt. Pleasant NC 28124
City State Zip • City State Zip
10. Deed Book No. 2085 Page No. 606 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 or firm is a sole
proprietorship,the name of the owner or manager may be listed as the financially responsible party.
MRT-1, LLC traganlexcominc.net
Name E-mail Address
PO Box 1234 1714 East Center Street
Current Mailing Address Current Street Address
Lexington NC 27293 Lexington NC 27292
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Jamestown Engineering Group, Inc. daniamestownengineering.com
Engineering Firm or other consultant E-mail Address
Daniel W. Pritchett, PE & PLS [phone] [phone]
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.
im Ragan Managing Member
Typ or p t Title or Authority
tri i4g11 /7'
Signature Date
I, Rt.--k-a_ _ GLtxA , a Notary Public of the County of ut_ i
State of North Carolina, hereby certify that [ iYYlD~ 1Ll 3 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this ra-4 day of 1\10`(-C-iN` t=1 , 20
AI
Rita C. Caudle Notary
Sekibtary Public
Davidson County, NC My commission expires 45- - D=
My Commission Expires 3-a o-2 L