NCC241057_FRO Submitted_20240604

NC Department of
Environmental Quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT JUN 13 2023
No person may initiate any land-disturbing activity on one or more acres as covered by the A4nifitqurldind,"
activity under a common plan of development of this size as covered by the NCGO1 permits,befewitlhiSJOM1
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: Somerton Subdivision
2. Location of land-disturbing activity: County Davidson City or Township Lexington
Highway/Street Bethesda Road Latitude (decimal degrees) 35-53-24 N Longitude(decimal degrees)80-13-46 W
3. Approximate date land-disturbing activity will commence: October 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13.64 +/-acres
6. Amount of fee enclosed: $ 910.00 &$2,000. 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 ❑x 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# Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Fat Porgy, LLC
Name Phone: Office# Mobile#
150 Bunker Hill Court
Current Mailing Address Current Street Address
Winston-Salem, NC 27107
City State Zip City State Zip
10. Deed Book No. Page No. 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 Same
Current Mailing Address Current Street Address
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, Suite 200
Current Mailing Address Current Street Address
Raleigh, NC 27615 Same
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 instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
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Type or print ame -itle or Authority
6/i/Zo23
ig ature Date /
SC..-M , a Notary Public of the County of{-)uk\F��
State of North Carolina, hereby certify that -vv 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 day of S , 20 2)
CN ry
My commission expires 1z f
.""" Priscilla R.Bravo
J;r fFys'4;
NOTARY PUBLIC
Guilford County,NC
My Commission Expires September 18,2027