NCC240650_FRO Submitted_20240312

Check if this project impaertad9esuof
Attach a copy of the Letters iirtrii4if ed
uality
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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JAP1 05 2024
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the AWiR6lt iqW
activity under a common plan of development of this size as covered by the NCGO1 permit, rktf,grortitObrrike
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 NC Hwy 8 Subdivision
'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).
Davidson Healing Springs Township
2. Location of land-disturbing activity: County City or Township
NC Hwy8 35.64N -80.23W
Highway/Street LatltUde(decimal degrees) LongltUde(decimal degrees)
3. Approximate date land-disturbing activity will commence: 7/11/22
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10
6. Amount of fee enclosed: $0.00 . 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 I] Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kurt Stawarz E-mail Address [e-mail]
Phone: Office# 336.517.2738 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
WJH LLC a Delaware Limited liability company 336-517-2759
Name Phone: Office# Mobile#
3091 Governors Lake Drive Suite 300 3091 Governors Lake Drive Suite 300
Current Mailing Address Current Street Address
Norcross GA 30071 Norcross GA 30071
City State Zip City State Zip
10. Deed Book No. DE 2621 Page No. 208-210 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).
WJH LLC [e-mail]
Company Name E-mail Address
3091 Governors Lake Drive Suite 300 3091 Governors Lake Drive Suite 300
Current Mailing Address Current Street Address
Norcross GA 30071 Norcross GA 30071
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:
CT Corporation
Name of Registered Agent E-mail Address
160 Mine Lake Court 160 Mine Lake Court
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Phone: Office# Mobile#
Kurt Stawarz
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 instrumen for the Financially Responsible Party). I agree to provide
corrected information should thereany change in the information provided herein.
Kurt Stawarz . - •.e al President
Type or pri t n.A - Title or Authority
illeillw
;_...„, ..' 1/4/24
ignature' Date
1, a..^'' 1 . . -( tl , a Notary Public of the County of L.9-u i ( C,.>,- c(
State of North Carolina, hereby certify that V- A‘-fi S.1- w c,v'2 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 Lt day of Uvv...c-.A , 20 2-'-►
ir
LAURIE S. HOGLUND Notary �/
Notary Publla,ENorth Carolina — (� ' 2 J Z q Guilford County My commission expires
My Commission Expires
01-06-2029