NCC241816_FRO Submitted_20240613

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 Bloom Subdivision - South
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121)below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Harnett City or Township Hector's Creek
Highway/Street Spence Mill Road Latitude decimal de reel 35.526526 -78.822135
( g ) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence:4/15/24
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 35.0
6. Amount of fee enclosed:$3500 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Joseph P Conlan E-mail [e-mail]
Phone: Office# 919-833-3886 Mobile# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
CLAUDIA E.DOVE&DEBORAH D.SMITH
Name Phone: Office# Mobile#
7412 Harps Mill Rd
Current Mailing Address Current Street Address
Raleigh, NC 27615
City State Zip City State Zip
Page No.0681
10. Deed Book No.2356 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).
Mattamy Homes, LLC [e-mail]
Company Name E-mail Address
11000 Regency Parkway, Suite 110 SAME
Current Mailing Address Current Street Address
Cary, NC 27518
City State Zip City State Zip
Phone: Office#919-833-3886 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:
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)
(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
correcte information should there be any change in the information provided herein.
obeeki P Cowin VP timo Deve-topnlarr
Type o print name Title or Authority
miti
10Y
Signa ltr re Date
I,t,U +t Kv,-11c.c-i.r , a Notary Public of the County of L-`2
State of North Carolina,hereby certify that-4 • P CC"A"'3 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
nci
Witness my hand and notarial seal,this a day of-may AaL' �^i ,20 k4-
26,62
r Notary
dei``� V" �� My commission expires t''nP':Z' a"t ,deD2'S
,c.
1. NOTARY
nrrl
PUBLIC rc
NO °``p
_J

N.C. Department of Environmental Quality
Land Quality Section
Fayetteville Regional Office
225 Green Street,Suite 714
Fayetteville, NC 28301
RE: Bloom Subdivision
To Whom It May Concern:
As the landowners of record for parcel identified as having PIN 0654-24-3186, located on the north and south sides
of Spence Mill Road in Harnett County, I authorize Mattamy Homes, LLC to submit an erosion control plan and
conduct the anticipated land disturbing activity.
Sincerely,
CPAA) SUL 0177Ar
Claudia E. Dove Deborah D.Smith
1,DOrialial63 Notary Public of the County of Wcis e ,State of North Carolina,
hereby certify that CIU ►ct Cove ""LLLoQc+h D. eared personally before me this day and being duly
sworn acknowledged that the above form was executed by them.
Witness my hand and notarial seal,this 3 day of„Sa1('x 2. ,2024
avE N ",,,.
.10
▪p ;• cJ +�;�� Notary
0r�� r1OTARy Tel(J) My ExpiresJOY CO/Zo27
_ PUBLIC = Commission
',''%41 COUN