NCC240312_FRO Submitted_20240209

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 Legacy Academy - Phase 2
*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 Rockingham City
or Township Reidsville
Highway/Street S Scales St. Latltude(decimal degrees)36 31 6 Longitude(decimal degrees) _79.672
3. Approximate date land-disturbing activity will commence: 9/15/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.2
6. Amount of fee enclosed: $900.00 . 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 El Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chad E. Abbott E-mail Address [e-mail]
Phone: Office# 919-230-0996 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
David M. Vaughn - -
Name Phone: Office# Mobile#
201 Chickasaw Dr.
Current Mailing Address Current Street Address
Reidsville, NC 27320-7627
City State Zip City State Zip
730/1457/1059/1656 772/2627/2312/1370
10. Deed Book No. Page No. 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).
Hubrich Contracting, Inc. [e-mail]
Company Name E-mail Address
4321 Medical Park Dr. Suite #100 4321 Medical Park Dr. Suite #100
Current Mailing Address Current Street Address
Durham, NC 27704 Durham, NC 27704
City State Zip City State Zip
Phone: Office# 9 1 9-47 1.I -2895 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:
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)

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:
Kenneth M. Vaughn
Name Phone: Office# Mobile#
201 Chickasaw Dr.
Current Mailing Address Current Street Address
Reidsville, NC 27320-7626
City State Zip City State Zip
Deed Book No.730/1457/1059 Page No.772/2627/2312 Provide a copy of the most current deed.
Landowner 3 of Record:
American Charter Development, LLC
Name Phone: Office# Mobile#
725 West 1200 North Suite 100
Current Mailing Address Current Street Address
Springville, UT 84663
City State Zip City State Zip
Deed Book No. 1656 Page No. 1 370 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.

(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.
Steve Hubrich President
Type or_print name Title or Authority
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Signature Date
I, L t(`cta_ yleuJYLQ rfi , a Notary Public of the County of +JL c ka. rn
State of North Carolina, hereby certify that RAN e �1 u b F cc 1-- 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 k day of :t eC 'MX3.e I , 20 2-)
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LAND OWNER'S CONSENT TO FILE APPLICATION
I, Am.Pwi r."... lieu eYA-4 , (Legal Land Owner of Property)do
hereby authorize,Steve Hubrich (Applicant)and/or his assigns,to make application for the
property described as"Lot 1B" in Rockingham County DB 1656 PG 1370.This property is owned
by those listed herein or their assigns and hereby grant permission to the "Applicant"to apply,
submit plans, interact, accept permits, and commence construction/disturbance for the
property referenced herein.
SIGN
SIGNED:
SIGNED:
DATE: 12 /I ./2"'S