NCC231849_FRO Submitted_20230616

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 Southport Meadows
*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 Brunswick City or Township
Long Beach Rd SE(NC 133) 33 96601751 -78 03600739
Highway/Street Latitude(decimal degrees) Longltude(decimai degrees)
3. Approximate date land-disturbing activity will commence.June 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 62.17 AC
6. Amount of fee enclosed: $6,300 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:
Name Jamison Fair E-mail [e-mail]
Phone: Office# 910-232-6962 Mobile#
9 Landowner(s) of Record (attach accompanied page to list additional owners):
Cameron Properties Timber Company, LLC
Name Phone: Office# Mobile#
PO Box 3649
Current Mailing Address Current Street Address
Wilmington NC 28406
City State Zip City State Zip
10. Deed Book No. 003933 Page No.00619 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)maybe listed as the financially responsible party(ies).
Pulte Home Company, LLC [e-mail]
Company Name E-mail Address
4136 Passerine Ave
Current Mailing Address Current Street Address
Wilmington NC 28416
City State Zip City State Zip
Phone: Office# 910-232-6962 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:
Pulte Home Company, LLC [e-mail]
Name of Registered Agent E-mail Address
1225 Crescent Green Drive, Suite 250
Current Mailing Address Current Street Address
Cary, North Carolina 27518
City State Zip City State Zip
Phone: Office# 919- 8 I Ge- (I!ot Mobile#
Chris Raughley
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.
Chris Raughley VP of Land Development
Type or print name Title or Authority
Signature Date
I, yak\ -QSSQ�,� a Notary Public of the County of Wa\fle
State of North Carolina, hereby certify that Yr\ R1auq(1 I appeared personally
before me this day and being duly sworn acknowledged that the above for was executed by him/her.
Witness my hand and notarial seal, this 1 day of r\ \ , 20 23
\EY'P RES i,, 1 2C, Na.1
',, Notary
z. TA R Y My commission expires 2 I Z.j1 2_,1
PUBLIC
OOUNl,``�v`.

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:
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 3 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 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.

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.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#