NCC241784_FRO Submitted_20240617

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 MARBLE GRANITE WORLD
*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 FORSYTH City or Township KERNERSVILLE
ROUTE NC-66/317 E BODENHAMER ST
Highway/Street Latitude(decimal degrees)36.11939 Longitude(decimal degrees) -80.068
3. Approximate date land-disturbing activity will commence: APRIL 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): COMMERCIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.05 AC
6. Amount of fee enclosed: $ 300 . 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 JOSEPH A. HAGE E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
ZUZU INVESTMENT PROPERTIES LLC [phone] [phone]
Name Phone: Office# Mobile#
317 E BODENHAMER ST 317 E BODENHAMER ST
Current Mailing Address Current Street Address
KERNERSVILLE NC 27284-2837 KERNERSVILLE NC 27284-2837
City State Zip City State Zip
DB 3748 PG 1297
10. Deed Book No. DB 3591 PG 3167 Page No. Provide a copy of the most current deed.
DB 3655 PG 3000
DB 3738 PG 1665
DB 3715 PG 1028

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).
ZUZU INVESTMENT PROPERTIES LLC [e-mail]
Company Name E-mail Address
317 E BODENHAMER ST 317 E BODENHAMER ST
Current Mailing Address Current Street Address
KERNERSVILLE NC 27284-2837 KERNERSVILLE NC 27284-2837
City State Zip City State Zip
Phone: Office# [phone] 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
corrected information should there be any change in the information provided herein.
.JAMILE C. HAGE MEMBER
Type or print name Title or,
pAuthority
/A /,`2‘).2Zi
.Ignature D e
I, 0 O.XL Ct F1 f IF , a Notary Public of the County of 1-069'4
State of North Carolina, hereby certify that U r I I e ( Req 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 dIrl day of l--bfktur , 20 a4,
CJ&L0A
1_,Afht_t_
Notary
CARLA FLYNT
Notary Public My commission expires n
Forsyth Co., North Carolina
My Commission Expires Dec.17,2028

EROSION and SEDIMENTATION CONTROL PLAN PRELIMINARY REVIEW CHECKLIST
The following items shall be incorporated with respect to specific site conditions,in an erosion&sedimentation control plan:
NPDES Construction Stormwater General Permit NCG010000
J Designation on the plans where the 7 or 14 day ground stabilization requirements apply per Part II.E.1 of the permit.
J Design of basins with one acre or more of drainage area for surface withdrawal as per Part II.B.8 of the permit.
LOCATION INFORMATION ✓ Name and classification of receiving water course or name of
municipal operator(only where stormwater discharges are to occur)
J Project location&labeled vicinity map(roads,streets,landmarks)
J North arrow and scale STORMWATER CALCULATIONS
✓ Identify River Basin.
J Provide a copy of site located on applicable USGS quadrangle and ✓ Pre-construction runoff calculations for each outlet from the site(at
NRCS Soils maps if it is in a River Basin with Riparian Buffer peak discharge points). Be sure to provide all supporting data for
requirements. the computation methods used (rainfall data for required storm
events, time of concentration/storm duration, and runoff
GENERAL SITE FEATURES(Plan elements) coefficients).
✓ Design calculations for peak discharges of runoff (including the
✓ Property lines&ownership ID for adjoining properties construction phase&the final runoff coefficients for the site)
✓ Existing contours(topographic lines) ✓ Design calcs for culverts and storm sewers (include HW, TW and
J Proposed contours outlet velocities)
J Limits of disturbed area(provide acreage total,delineate limits,and ✓ Discharge and velocity calculations for open channel and ditch
label). Be sure to include all access to measures, lots that will be flows(easement&rights-of-way)
disturbed,and utilities that may extend offsite. ✓ Design calcs for cross sections and method of stabilization for
✓ Planned and existing building locations and elevations existing and planned channels(include temporary linings). Include
J Planned&existing road locations&elevations,including temporary appropriate permissible velocity and/or shear stress data.
access roads J Design calcs and construction details for energy dissipaters below
J Lot and/or building numbers culvert and storm sewer outlets (include stone/material specs &
✓ Hydrogeologic features: rock outcrops, seeps, springs, wetland apron dimensions).Avoid discharges on fill slopes.
and their limits, streams, lakes, ponds, dams, etc. (include all ✓ Design calcs and dimension of sediment basins (note current
required local or state buffer zones and any DWQ Riparian Buffer surface area and dewatering standards as well as diversion of
determinations) runoff to the basins). Be sure that all surface drains, including
J Easements and drainageways, particularly required for offsite ditches and berms,will have positive drainage to the basins.
affected areas. Include copies of any recorded easements and/or
agreements with adjoining property owners. VEGETATIVE STABILIZATION
J Profiles of streets,utilities,ditch lines,etc.
✓ Stockpiled topsoil or subsoil locations J Area&acreage to be stabilized with vegetation
J If the same person conducts the land-disturbing activity & any ✓ Method of soil preparation
related borrow or waste activity,the related borrow or waste activity ✓ Seed type&rates(temporary&permanent)
shall constitute part of the land-disturbing activity unless the borrow J Fertilizer type and rates
or waste activity is regulated under the Mining Act of 1971, or is a J Mulch type and rates(include mulch anchoring methods)
landfill regulated by the Division of Waste Management. If the land-
disturbing activity and any related borrow or waste activity are not NOTE: Plan should include provisions for groundcover in accordance with
conducted by the same person,they shall be considered separate NPDES Construction Stormwater General Permit NCG010000.
land-disturbing activities and must be permitted either through the
Sedimentation Pollution Control Act as a one-use borrow site or FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
through the Mining Act.
✓ Location and details associated with any onsite stone crushing or J Completed,signed&notarized FR/O Form
other processing of material excavated. If the affected area ✓ Accurate application fee payable to NCDEQ ($100.00 per acre
associated with excavation,processing,stockpiles and transport of rounded up the next acre with no ceiling amount)
such materials will comprise 1 or more acres,and materials will be J Certificate of assumed name,if the owner is a partnership
leaving the development tract,a mining permit will be required. ✓ Name of Registered Agent(if applicable)
J Required Army Corps 404 permit and Water Quality 401 J Copy of the most current Deed for the site. Please make sure the
certification(e.g.stream disturbances over 150 linear feet) deed(s)and ownership information are consistent between the plan
sheets,local records and this form.
EROSION&SEDIMENT CONTROL MEASURES(on plan) ✓ Provide latitude & longitude (in decimal degrees) at the project
entrance.
✓ Legend (provide appropriate symbols for all measures and ✓ Two hard-copies of the plans (some regional offices require
reference them to the construction details) additional plans or multiple sizes; please contact the regional
✓ Location of temporary measures coordinator prior to such submittal.)
J Location of permanent measures
J Construction drawings and details for temporary and permanent NOTE: For the Express Permitting Option, inquire at the local Regional
measures. Show measures to scale on plan and include proposed Office for availability. Express Reviews are performed by
contours where necessary. Ensure design storage requirements appointment only.
are maintained through all phases of construction.
✓ Maintenance requirements for measures NARRATIVE AND CONSTRUCTION SEQUENCE
✓ Contact person responsible for maintenance
✓ Narrative describing the nature & purpose of the construction
SITE DRAINAGE FEATURES activity.
J Pre-construction conference, if requested.
J Existing and planned drainage patterns (include off-site areas that J Construction sequence related to erosion and sediment control
drain through project and address temporary and permanent (including installation of critical measures prior to the initiation of the
conveyance of stormwater over graded slopes) land-disturbing activity & removal of measures after areas they
J Method used to determine acreage of land being disturbed and serve are permanently stabilized). Address all phases of
drainage areas to all proposed measures(e.g.delineation map) construction and necessary practices associated with temporary
✓ Size,pipe material and location of culverts and sewers stream bypasses and/or crossings.
✓ Soil information: type,special characteristics J Bid specifications related only to erosion control
✓ Soil information below culvert storm outlets
rev. 1-18-22