NCC232575_FRO Submitted_20230926

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Campbell Ridge Subdivision
2. Location of land-disturbing activity: County Harnett City or Township Black River
Highway/StreetOld Stage Road Latitude{decimal degrees) 354808 Long ltUde(decimaldegrees) -78.6959
3. Approximate date land-disturbing activity will commence: September 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 29.33
6. Amount of fee enclosed 3000.000 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). 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 Brian O'Kane E-mail Address [e-mail]
Phone: Office# 919-435-6395 ext 6 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jane Marie Campbell Yarborough and Betty Sue Campbell Avery Jane Marie-919-210-6891 Betty Sue-910-65B-0800
Name Phone: Office# Mobile#
PO Box 548 60 Lake Eva Marie Drive
Current Mailing Address Current Street Address
Willow Spring NC 27592 Raleigh NC 27603
City State Zip City State Zip
10. Deed Book No. 705 Page No.253 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).
DRB Group North Carolina, LLC cmyrman(cz�,drbgroup.com
Company Name Email Address
3000 RDU Center Drive, Suite 202 3000 RDU Center Drive, Suite 202
Current Mailing Address Current Street Address
Morrisville NC 27560 Morrisville NC 27560
City State Zip City State Zip
Phone: Office* 919-747-4970 x4005 Mobile# 919- 747-4970 x4005
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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

1 3
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
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:
The Nau Company [e-mail]
Engineering firm or other consultant E-mail Address
Brian O'Kane 252-702-1910 252-702-1910
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.
Craig Myrman Vice President
Typedr print name Title or Authority
lTIAA-1--
7/,‘/un
Signatur Date
I, Am .1-44.1.,-.4-41 e✓7.-- , a Notary Public of the County of
State of North Carolina, hereby certify that CA"'"GU r I appeared personally
before me this day and being duly sworn acknowledged tht the above form was executed by him/her.
Witness my hand and notarial seal, this /54 `day of AU jUs1- , 20 2Z
- AMANDA L MARTINEZ
Notary Public, North Carolina Notary
Wake County
My Commission Expires 8 - 13 -20ZY
Auiicst 13,2024 My commission expires

.
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:
Betty Sue Campbell Avery N/A N/A
Name Phone: Office# Mobile#
125 Joy Street 125 Joy Street
Current Mailing Address Current Street Address
Dunn NC 28334 Dunn NC 28334
City State Zip City State Zip
Deed Book No. 705 Page No.253 Provide a copy of the most current deed,
Landowner 3 of Record:
Jane Marie Campbell Yarborough N/A N/A
Name Phone: Office# Mobile#
60 Lake Eva Marie Drive 60 Lake Eva Marie Drive
Current Mailing Address Current Street Address
Raleigh NC 27603 Raleigh NC 27603
City State Zip City State Zip
Deed Book No. 705 Page No.253 Provide a copy of the most current deed.
Landowner 4 of Record:
Jackie Glenn Campbell N/A N/A
Name Phone: Office# Mobile#
5574 NC-210 N 5574 NC-210 N
Current Mailing Address Current Street Address
Angier, NC 27501 Angier, NC 27501
City State Zip City State Zip
Deed Book No.705 Page No.253 Provide a copy of the most current deed.
Landowner 5 of Record:
Timothy Woodrow Campbell N/A N/A
Name Phone: Office# Mobile#
5030 Old Stage Road 5030 Old Stage Road
Current Mailing Address Current Street Address
Angier NC 27501 Angier NC 27501
City State Zip City State Zip
Deed Book No. 705 Page No.253 Provide a copy of the most current deed.