NCC241174_FRO Submitted_20240417

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FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JAN
28 2022
SEDIMENTATION POLLUTION CONTROL ACT
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No person may initiate any land disturbing activity on one or more acres as covered bye aerrA440
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 and/
or fax information unavailable, place N/A in the blank.)
Part A. 5101 Stack Rd Lot #1
1. Project Name
2. Location of land-disturbing activity: County Union City or Township Buford Township
Highway/Street Stack Rd (SR 2115) Latitude 34.827274 Longitude -80.452517
3. Approximate date land-disturbing activity will commence:September 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.32
6. Amount of fee enclosed: $ 195 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Starnes E-mail Address [e-mail]
Telephone [phone] Cell# 704-254-6710 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brother's Housing & Real Estate, Inc 843-675-7555 843-675-7717
Name Telephone Fax Number
1406 South Van L. Mungo Blvd 1406 South Van L. Mungo Blvd
Current Mailing Address Current Street Address
Pageland SC 29728 Pageland SC 29728
City State Zip City State Zip
10. Deed Book No. 8026 Page No. 0023 & 24 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Brothers Housing & Real Estate, Inc [e-mail]
Name — E-mail Address
1406 South Van L. Mungo Blvd 1406 South Van L. Mungo Blvd
Current Mailing Address _ Current Street Address
Pageland SC 29728 Pageland SC 29728
City State Zip City State Zip
Telephone [phone] Fax Number 843-675-7717

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:
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Name E-mail Address
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Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone ��� Q� �," Fax Numbest ^
(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:
WOLV(VL—II) 66‘ (5-Varing hail-4,4 LAM(qc,641 flo, t,cyyl i
Name of Registered Agent E-mail Address
3ri PaithIVOOd ,-SChOD' Oci ,3M PcurrakiwcA &.-hool eci ,,
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Current�M/ailing Address p Current Street Address
City State Zip City State Zip
Telephone ��� Fax Number
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 iriformatio should the b any change in the information provided herein.
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I, .�US7" h , a Notary Public of the County of Gkf'�e-i ela�J- - Car1(Yii
���'lt'r 6614 Sfn r )/ appeared State of - a, herebycertifythatpp
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this `i day of vJ , 20 a
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