NCC240704_FRO Submitted_20240312

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
0 EROSION & SEDIMENTATION CONTROL
IREDELLNo person may initiate any land-disturbing activity on one or more acres, '/ acre or more inside a
COUNTY NC watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning &Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name Larkin Golf Club
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street 175 Club House Dr Latitude 35.748056 deg Longitude -80.871111 deg
3. Approximate date land-disturbing activity will commence: March 1, 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.72
6. Amount of fee enclosed: $ 1,050 . An application fee of$175.00 per acre(rounded up to the next acre)is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of$100.00 is assessed.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Todd Senff E-mail Address [e-mail]
Telephone N/A Cell# 330-495-1733 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
DG Golf Holdings, LLC 330-495-1733 N/A
Name Telephone Fax Number
170 Raceway Drive, Suite C same
Current Mailing Address Current Street Address
Mooresville, NC 28117-6521 same
City State Zip City State Zip
10. Deed Book No. 2984 Page No. 1952 Provide a copy of the most current deed.
Part B.
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet):
DG Golf Holdings, LLC [e-mail]
Name E-mail Address
170 Raceway Drive, Suite C same
Current Mailing Address Current Street Address
Mooresville, NC 28117-6521 same
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated
North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name, attach
a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, give name and street
address of the Registered Agent:
Todd Senff [e-mail]
Name of Registered Agent E-mail Address
19701 Bethel Church—Suite 103-313 same
Current Mailing Address Current Street Address
Cornelius, NC 28031 same
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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 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 Person). I agree to
provide corrected information should there by any change in the information provided herein.
Ty print e Title or Authority
ignature 1 Date /
I, O,,i-0 r cut i ta ,a NotaryPublic of the County of r-` C� ` h
tY
State of North Carolina, hereby certify that C' 'e h f I appeared personally before me this day
and being duly sworn acknowledged that the a¢,pve form was executedl by him 23
Witness my hand and notarial seal,this 3 0 day of OC�b v Er . 20
�Q b
Notary
Seal . 1
My commission expires iV M csi 1 �1}-2g
�/
CAROL K.PALILLO
Notary Public-North Carolina
Mecklenburg County
I My Commission Expires Jul 21,2028
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