NCC232277_FRO Submitted_20230731

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 NCG01 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 The Village on Sunset Lot 5
*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 Sampson City or Township North Clinton Township
Highway/Street Village Circle Latitude(decimal degrees)34.994335 Longitude(decimal degrees)-78.359463
3. Approximate date land-disturbing activity will commence. April 10, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.47 acres
6. Amount of fee enclosed: $ 100.00 . 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 X Enclosed X No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Walter Carr E-mail Address geraldinecarr122agmail.con
Phone: Office# 910-990-4449 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners).
Walter F. Carr and Geraldine Carr 910-990-4449 910-990-4449
Name Phone: Office# Mobile#
229 Airport Road 229 Airport Road
Current Mailing Address Current Street Address
Clinton NC 2SJ2 { Clinton NC 28329
City State Zip City State Zip
10. Deed Book No. 2154 Page No. 446 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).
W. F. Carr Construction Company, Inc. geraldinecarr122(cr�gmail.com
Company Name E-mail Address
229 Airport Road 229 Airport Road
Current Mailing Address Current Street Address
Clinton NC 28329 Fayetteville NC 28329
City State Zip City State Zip
Phone: Office# 910-990-4449 Mobile# [phone]
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 attomey-in-fact, or if not an individual, by an officer, director, partner, or
registered agent with the authonty to execute instruments for the Financially Responsible Party). I
agree to provide corrected information should there be any change in the information provided
herein.
Walter Carr Owner/Manager
Type or pnnt name Title or Authonty
0:2£t'1 c/ ,. '1�. 03r3112023
Signature Date
I, Lon Simpson Ealer a Notary Public of the County of Cumberland
State of North Carolina, hereby certify that Walter Carr appeared 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 31th day of March 24
J --
Notary Public Notary
Geri Sirapsea Epler
Camberlani County My commission expires 11-14-2024
North Carolina