NCC241573_FRO Submitted_20240522

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part .roject Name Chestnut Creek Lot 14
1 . P
2. Location of land-disturbing activity: CountyChatham City or TownshipChpl Hill
Hi hwa /Street 271 Walnut Branch '
9 Y Latitude 35'362 Longitude 79. 18
3. Approximate date land-disturbing activity will commence:5127/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.):residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): .903
6. Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kirk T. Metty E-mail [e-mail]
Telephone [phone] Cell # 919.235.2077 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kacey Baughn 336.705.3169
Name Telephone Fax Number
342E 300 N
Current Mailing Address Current Street Address
Spanish Fork, UT 84660
City State Zip City State Zip
10. Deed Book No.02408 Page No.0438 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.
The Tuscan Group, Inc [e-mail]
Name E-mail Address
661 Cedar Grove Rd 661 Cedar Grove Rd
Current Mailing Address Current Street Address
Pittsboro NC 27312 Pittsboro NC 27312
City State Zip City State Zip
Telephone [phone] Fax Number

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:
Name of Registered Agent E-mail Address
Current Mailing Address 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 information should there be any change in the information provided herein.
Kirk T. Metty President
Typ b Title or Authority
5/21/24
Signature Date
I, OQ \Y' CJ. C�,�N m e\, a Notary Public of the County of t1 1G'- \
State of North Carolina, hereby certify that �(V- T. ' I., appeared
personally before me this day and being duly sworn acknowledge that the above form was
executed by him.
Witness my hand and notarial seal, this al day of l v ` AAl , 20 a�
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