NCC232490_FRO Submitted_20230817

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 Atkins Farm
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Forsyth City or Township Kernersville
Watkins Ford Road 36.04311 -80.08688
Highway/Street Latltude(decimaldegrees) Longitude(decimaldegrees)
3. Approximate date land-disturbing activity will commence: August 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.09
6. Amount of fee enclosed: $200.00 . 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 No D
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David Michaels E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners): (See Attached, List of Landowners)
Land Acquisition and Development Services, LLC [phone]
Name Phone: Office# Mobile#
P.O. Box 9147 1007 Battleground Avenue, Ste 301
Current Mailing Address Current Street Address
Greensboro, NC 27429 Greensboro, NC 27408-8313
City State Zip City State Zip
10. Deed Book No. 3752 Page No.664 Provide a copy of the most current deed.
(PIN #6873-96-3812)

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).
Land Acquisition and Development Services, LLC [e-mail]
Company Name E-mail Address
P.O. Box 9147 1007 Battleground Avenue, Ste 301
Current Mailing Address Current Street Address
Greensboro, NC 27429 Greensboro, NC 27408-8313
City State Zip City State Zip
Phone: Office# 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:
Thomas C. Hall [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 9147 1007 Battleground Avenue, Ste 301
Current Mailing Address Current Street Address
Greensboro, NC 27429 Greensboro, NC 27408-8313
City State Zip City State Zip
Phone: Office# [phone] 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 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.
David Michaels Company Agent for Land Acquisition and Development Services, LLC
Ty e o ri a Title or Authority
7//CI
Sight re Date
•
I, kl`1 ✓1 P) Sri , a Notary Public of the County of &A t -IZ;
State of North Carolina, hereby certify that tj,11 M ( Gii(t appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
11
Witness my hand and notarial seal, this )d day of la V , 20 >9
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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.
***RECORDED EASEMENTS and DEEDS (See attached):
Landowner 2 of Record:
Brunswick at Caleb's Creek HOA
Name Phone: Office# Mobile#
2311 W Cone Blvd, Ste 150 Same
Current Mailing Address Current Street Address
Greensboro, NC 27408
City State Zip City State Zip
Deed Book No. 3744 Page No. 1431 Provide a copy of the most current deed.
(***Easement Deed for Sanitary Sewer System)
Landowner 3 of Record:
Bobby L. Chestnutt
Name Phone: Office# Mobile#
7475 Watkins Ford Road Same
Current Mailing Address Current Street Address
Kernersville, NC 27284
City State Zip City State Zip
Deed Book No. 3740 Page No. 1693 Provide a copy of the most current deed.
(***Easement Deed for Sanitary Sewer System)
Landowner 4 of Record:
Jennifer H. Lee
Name Phone: Office# Mobile#
7485 Watkins Ford Road
Current Mailing Address Current Street Address
Kernersville, NC 27284
City State Zip City State Zip
Deed Book No. 3740 Page No. 1699 Provide a copy of the most current deed.
(***Easement Deed for Sanitary Sewer System)
Landowner 5 of Record:
Theodora C. Katsis
Name Phone: Office# Mobile#
1086 Old Stone Lane Property Address: "0" Watkins Ford Road
Current Mailing Address Current Street Address
Kernersville, NC 27284
City State Zip City State Zip
Deed Book No. 3439 Page No. 504 Provide a copy of the most current deed.
(***Petition For Condemnation of Right-of-Way", filed with Clerk of Forsyth County, NC, on March 21, 2023;
Amended Petition For Condemnation of Right-of-Way, filed with Clerk of Forsyth County, NC, on 07/14/2023.)