NCC240934_FRO Submitted_20240402

Check if this project is ARPA-funded ❑
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 NCGO1 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 Collier Gate Estates—Lots 1, 2, 9-11, 43, 44, 55, 57 & 58
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project IVame below
under which you applied for funding through the Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Cumberland City or Township Carvers Creek Township
Godwin Gate Street
Highway/Street &Vega Lane Latitude(dectma,degfee) N 35.2588° Longitude,d°°;,,,a,--,W-78.8221°
3. Approximate date land-disturbing activity will commence: March 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.67 Acres
6. Amount of fee enclosed: $ 500.00 . 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Hannah McGrath E-mail Address permittinqAbenstoutconstruction.com
Phone: Office# 910-779-0019 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
AGS LAND, LLC 910-779-0019
Name Phone: Office# Mobile It
1786 Metromedical Drive Same
Current Mailing Address Current Street Address
Fayetteville NC 28304 Same
City State Zip City State Zip
10. Deed Book No. 11340 Page No. 523 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).
Benjamin Stout Real Estate Services, Inc. briannbenstoutconstruction.corn
Company Name E-mail Address
1786 Metromedical Drive Same
Current Mailing Address Current Street Address
Fayetteville NC 28304 Same
City State Zip City State Zip
Phone: Office# 910-779-0019 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:
Benjamin Stout benbenstoutconstruction.com
Name of Registered Agent E-mail Address
1786 Metromedical Drive Same
Current Mailing Address Current Street Address
Fayetteville NC 28304 Same
City State Zip City State Zip
Phone: Office# 910-779-0019 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).
agree to provide corrected information should there be any change in the information provided
herein.
Brian D. Walker President
Type or print
name Title or Authority
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Signature Date
I, Ren(i-rd(A E• Z'Ncc 5 , a Notary Public of the County of C.,I,,CYA ,P
sINCI
State of North Carolina, hereby certify that ifh(1—0• cD+�`C.P,r 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 ado day of c )<i {'�{J , 20,D4
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