WQ0044900_Application (FTSE)_20240624

DocuSign Envelope ID F573FE13 F84C-423A A6K0-BF372FA8C895
State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
FAST TRACK SEWER SYSTEM EXTENSION APPLICATION
Division of Water Resources FTA 10-23&SUPPORTING DOCUMENTATION
AppIi cation Number:XgCO 00 AfljP(to becompleledbyDWR)
All items must be completed or the application will be returned
1. APPLICANT INFORMATION:
1. Applicant's name: Heritage Crossing Holdings LLC(company,municipality, HOA,utility,etc.)
2. Applicant type: ❑ Individual ®Corporation ❑General Partnership ❑Privately-Owned Public Utility
❑ Federal ❑State/County ❑Municipal [ Other
3. Signature authority's name: Patrick Raynor per 1 SA NCAC 02T.010&bI
Title: Manager APR 2 5 M4
4. Applicant's mailing address: 639 Executive PI Suite 400
City: Fayetteville State: NC Zip: 28305-_
5. Applicant's contact information:
Phone number: [phone] Email Address:Patrick_,cavinessandcates.com
I1. PROJECT INFORMATION:
I. Project name: The Carolinian
2. Application/Project status: ❑Proposed(New Permit) ® Existing Permit/Project ❑ARPA funded
If a modification,provide the existing permit number:WQ0044900 and issued date: Feb 8. 2024,
For modifications,also attach a detailed narrative description as described in Item G of the checklist.
If new construction,but part of a master plan,provide the existing permit number: WQ00
3. County where project is located: Wilson
4. Approximate Coordinates(Decimal Degrees): Latitude: 35.7410 , Longitude:--77.970
S. Parcel ID(if applicable): 3702-56-5249(or Parce: ID to c;oscst downstream sewer)
111. CONSULTANT INFORMATION:
I. Professional Fnginecr: Ricardo Cocconcelh License Number:052319
Firm: WithersRavenel
Mailing address: 115 Mackenan Dr.
City Cary State: NC Zip: 27511-
Phone number: (9 i 99)469-3340 Email Address: rcocconcelli(a,withersrayencl.com
IV. WASTEWATER TREATMENT FACILITY(WWTF)INFORMATION:
1. Facility Name Hominy Creek Water Reclamation Facility Permit Number: NCO023906
Owner Name- City of Wilson
V. RECEIVING DOWNSTREAM SEWER INFORMATION:
1. Permit Number(s): WQCS0021
2. Downstream(Receiving)Sewer Information: 12 PVC inch Gravity LJ Force Main
3. System Wide Collection System Permit Number(s)(if applicable) WQCS00021
Owner Name(s) City of Wilson
FORM: FTA 10-23 Page I of 5

DocuSign Envelope ID F573FE13-F84C-423A-A6F0-BF372FA8C895
V1. GENERAL REQUIREMENTS
1. If the Applicant is a Privately-Owned Public Utility,has a Certificate of Public Convenience and Necessity been attached?
❑ Yes ❑ No ® N'A
2. If the Applicant is a Developer of lots to be sold, has a Developer's Operational Agreement(FORM: DFV)been attached?
El Yes ❑No ®NA
3. If the Applicant is a IIome/Property Owners'Association, has an HOA.WA Operational Aereement(FORM:110A)and
supplementary documentation as required by 15A NCAC 02T.01 15(c)been attached?
El Yes ❑No ®NA
4. Origin of wastewater:(check all that apply):
❑ Residential(Individually Owned) ❑ Retail(stores,centers,malls) ❑Car Wash
® Residential(Leased) ❑ Retail with food preparationr'servicc ❑ Hotel and or Motels
❑ School preschool!day care ❑ Medical dental veterinary facilities ❑ Swimming Pool:'Clubhouse
❑ Food and drink facilities ❑ Church ❑ Swimming PoolTilter Backwash
❑ Businesses offices r factories ❑ Nursing Home ❑Other(Explain in Attachment)
5. Nature of wastewater: 100 ko Domestic °-o Commercial %Industrial(See 15A NCAC 02T 0 103(20))
If Industrial,is there a Pretreatment Program in effect?❑Yes❑No
6. Has a flow reduction been approved under 15A NCAC 02T .01 HIM ❑ Yes ❑No
Z If yes,provide a cony of flow reduction approval letter with this application
7. Summarize wastewater generated by project:
Establishment Type(see 02T.0114(f)) Daily Design Flow°h No.of Units Flow
gaF GPD
gaV GPD
gale GPD
gale GPD
gale GPD
gaV GPD
Total GPD
a See 15A NCAC 02T.01 14(b),(d),(C)(I)and Lcl2j for caveats to wastewater design flow rates (i.e. proposed unknown
non-residential development uses; public access facilities located near high public use areas; and residential property
located south or east of the Atlantic Intracoastal Waterway to be used as vacation rentals as defined in G.S.42A4).
b Per 15A NCAC 02T.01 14(c),design flow rates for establishments not identified[in table 15A NCAC 02T.01 141 shall be
determined using available flow data,water using fixtures,occupancy or operation patterns,and other measured data.
8. Wastewater generated by project:0 GPD(per 15A NCAC 02T.0114 and G.S. 143-215.1)
s Do not include future flows or previously permitted allocations
If permitted flow is zero,please indicate why:
❑ Pump Station/Force Main or Gravity Sewer where flow will be permitted in subsequent permits that connect to this line.
Please provide supplementary infonnation indicating the approximate titneframc for permitting upstream sewers with flow.
® Flow has already been allocated in Permit Number: WQ0044900 Issuance Date: Feb 8.2024
❑ Rehabilitation or replacement of existing sewers with no new now expected
®Other(Explain): 40,500 GPD flow has been allocated to annroved permit W00044900.This is a modification to that
permit and includes NO additional flow.
FORM: FTA 10-23 Page 2 of 5

DocuSign Envelope ID F573FE13-F84C-423A-A6F0-BF372FA8C895
VII. GRAVITY SEWER DESIGN CRITERIA(If Applicable)-02T.0305& MDC(Gravity Sewers):
1. Summarize gravity sewer to be permitted:
Size(inches) Length(feet) Material
8" 3,355 LF PVC
➢ Section It&III of the MDC for Permitting of Gravity Sewers contains information related to design criteria
Section [if contains information related to minimum slopes for gravity sewer(s)
Oversizing lines to meet minimum slope requirements is not allowed and a violation of the MDC
Vlll. PUMP STATION DESIGN CRITERIA(If Applicable)—02T.0305& MDC(Pump Stations/Force Mains):
PROVIDE A SEPARATE COPY OF THIS PAGE FOR EACH PUMP STATION INCLUDED IN THIS PROJECT
. Pump station number or name:
2. Approximate Coordinates(Decimal Degrees): Latitude: Longitude:-
3. Total number of pumps at the pump station:
3. Design flow of the pump station: millions gallons per day(firm capacity)
This should reflect the total GPM for the pump station with the largest pump out of service.
4. Operational point(s)per pump(s): gallons per minute(GPM)at feet total dynamic head(TDI1)
5. Summarize the force main to be permitted(for this Pump Station):
Size(inches) Length (feet) Material
If any portion of the force main is less than 4-inches in diameter,please identify the method of solids reduction per
MDCPSFM Section 2.01 C I b. ❑Grinder Pump ❑ Mechanical Bar Screen ❑Other(please specify)
6. Power reliability in accordance with 15A NCAC 02T.0305(h)(1):
❑ Standby power source or ❑ Standby pump
D Must have automatic activation and telemetry- 15A NCAC 02T.0305(h)(1)(B),
Z Required for all pump stations with an average daily now greater than or equal to 15,000 gallons per day
S Must be permanent to facility and may not be portable
Or if the pump station has an average daily flow less than 15,000 gallons per day 15A NCACO2T.0305(h)(1)(C):
❑ Portable power source with manual activation,quick-connection receptacle and telemetry-
or
❑ Portable pumping unit with plugged emergency pump connection and telemetry:
➢ Include documentation that the portable source is owned or contracted by the applicant and is compatible with the station.
Z If the portable power source or pump is dedicated to multiple pump stations,an evaluation of all the pump stations storage
capacities and the rotation schedule of the portable power source or pump, including travel timeframes,shall be provided
as part of this permit application in the case of a multiple station power outage.
FORM: FTA 10-23 Page 3 of 5

Docu$ign Envelope ID:F573FE13-F84C•423A-A6F0-BF372FA8C895
IX. SETBACKS&SEPARATIONS—(02B.0200 & 15A NCAC 02T.0305(f)):
Does the project comply with all separations/alternatives found in t SA NCAC 02T.0305(fl& (e)? ® Yes ❑ No
15A NCAC 02T.0305 contains minimum separations that shall be provided for sewers stems:
Setback Parameter* Separation Required
Storm sewers and other utilities not listed below(vertical) 18 inches
Water mains(vertical -water over sewer preferred,including in benched trenches) 18 inches
'Water mains(horizontal) 10 feel
Reclaimed water lines(vertical -reclaimed over sewer) 18 inches
Reclaimed water lines(horizontal -reclaimed over sewer) 2 feet
**Any private or public water supply source, including any wells, WS-1 waters of Class I or
Class Ii impounded reservoirs used as a source of drinking water,and associated wetlands. 100 feet
**Waters classified WS(except WS-1 or WS-V), B, SA,ORW,HQW,or SB from normal
high water(or tide elevation)and wetlands associated with these waters(sec item IX.2) 50 feet
**Any other stream, lake,impoundment,or ground water lowering and surface drainage
ditches,as well as wetlands associated with these waters or classified as WL. 10 feet
Any building foundation(horizontal) 5 feet
Any basement(horizontal) 10 feet
Top slope of embankment or cuts of 2 feet or more vertical height 10 feet
Drainage systems and interceptor drains 5 feet
Any swimming pools 10 feet
Final earth grade(vertical) 36 inches
➢ if noncompliance with 02T.0305(f)or(g),see Section X.1 of this application
*15A NCAC 02T.0305(g)contains alternatives where separations in 02T,0305(f)cannot be achieved. Please check"yes"
above if these alternatives are used and provide narrative information to explain.
**Stream classifications can be identified using the Division's NC Surface Water Classificatior2iwebr_w
2. Does this project comply with the minimum separation requirements for water mains? ®Yes ❑No ❑N:A
➢ if no,please refer to 15A NCAC 18C.0906(0 for documentation requirements and submit a separate document,
signed/scaled by an NC licensed PE,verifying the criteria outlined in that Rule.
3. Does the project comply with separation requirements for wetlands? ❑Yes ❑No ®NIA
➢ Please provide supplementary information identifying the areas of non-conformance.
➢ See the Division's draft.seraration requirements for situations where separation cannot be met.
➢ No variance is required if the alternative design criteria specified is utilized in design and construction.
4. is the project located in a river basin subject to any State buffer rules? ❑ Yes Basin name: ®No
if yes,does the project comply with setbacks found in the river basin rules per 15A NCAC 02B .0200? ❑Yes ❑No
➢ This includes Trout Buffered Streams per 15A NCAC 213.0202
S. Does the project require coverage authorization under a 404 Nationwide individual permits ❑Yes ®No
or 401 Water Quality Certifications?
"r Please provide the permit number'permitting status in the cover letter if coverage authorization is required.
6. Does project comply with 15A NCAC 02T.0I051c1(6)(additional perm its,,certifications)? ®Yes ❑No
Per l5A NCAC 02T.0 I 05(ckft directly related environmental permits or certification applications must be being prepared,
have been applied for,or have been obtained. Issuance of this pen-nit is contingent on issuance of dependent permits(erosion
and sedimentation control plans,stormwatcr management plans,etc.).
7. Does this project include any sewer collection lines that are deemed"high-priority?" ❑Yes ®No
Per 15A NCAC 02T.0402,"high-priority sewer"means any aerial sewer,sewer contacting surface waters,
siphon,or sewers positioned parallel to streambanks that are subject to erosion that undermines or deteriorates the sewer
Siphons and sewers suspended through interference/conflict boxes require a variance approval.
➢ If yes, include an attachment with details for each line, including type(aerial line,size,material,and location).
High priority lines shall be inspected by the permittee or its representative at least once every six-months and
inspections documented per 15A NCAC 027.0403(a)(5)or the permittee's individual System-Wide Collection permit.
FORM: FTA 10-23 Page 4 of 5

DocuSign Envelope ID F573FE13-F84C-423A-A6F0-BF372FA8C895
X. CERTIFICATIONS:
I. Does the submitted system comply with 15A NCAC 02T, the Minimum Design Criteria for the Permitting of Pump Statii>tts
and Force Mains I latest version).and the Gravity Sewer Minimum Design Criteria(latest version]as applicable?
® Yes ❑No
If no, for projects requiring a single variance, complete and submit the Variancc.Alternative Design Request application
(VADC 10-14) and supporting documents for review to the Central Office. Approval of the request will be issued
concurrently with the approval of the permit, and projects requiring a variance approval may be subject to longer
review times. For ro'ects reouiring two or more variances or where the%ariance is determined by the Division to be a
sip-nificant portion of the project,the full technical review is required.
2. Professional Engineer's Certification:
Ricardo A. cocconcelli
1, ,attest that this application for The Carolinian
(Professional Engineer's name from Application Item III l ) (Project Name from Application hem II 1)
has been reviewed by me and is accurate, complete and consistent with the information supplied in the plans,
specifications,engineering calculations,and all other supporting documentation to the best of my knowledge. I further
attest that to the best of my knowledge the proposed design has been prepared in accordance with the applicable regulations,
Minimum Design Criteria for Gravity Sewers(latest version),and the Minimum Design Criteria for the Fast Track Permitting
of Pump Stations and Force Mains(latest version). Although other professionals may have developed certain portions of this
submittal package, inclusion of these materials under my signature and seal signifies that I have reviewed this material and
have judged it to be consistent with the proposed design.
NOTE In accordance with General Statutes 143 215.6A and 143-215.6131, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed$10,000,as well as civil penalties up to$25,000 per violation Misrepresentation of the application
information,including failure to disclose any design non-compliance with the applicable Rules and design criteria,may subject
the North Carolina-licensed Professional Engineer to referral to the licensing board.(21 NCAC 56.0701)
0006'404000o'oo,a
North Carolina Professional Engineer's seal,signature,and date: °°�N C p pOa,
OFESS/0°ooti o,
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3. Applicant's Certification per 15A NCAC 02T.0106(b):
Patrick Raynor The Carolinian
I, ,attest that this application for
(Signature Authority Name from Application item 13) (Project Name from Application Item II.1)
attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge.
1 understand that if all required parts of this application are not completed and that if all required supporting documentation
and attachments are not included, this application package is subject to being returned as incomplete. I understand that any
discharge of wastewater from this non-discharge system to surface waters or the land will result in an immediate enforcement
action that may include civil penalties, injunctive relief,and/or criminal prosecution. I will make no claim against the Division
of Water Resources should a condition of this permit be violated I also understand that if all required parts of this application
package are not completed and that if all required supporting information and attachments are not included, this application
package will be returned to me as incomplete.
NOTE In accordance with General Statutes 143-215.6A and 143-215 6B, any person who knowingly makes any false
statement, representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may
include a fine not to exceed S 10,000 as well as civil penalties up to$25,000 per violation.
DocuSigned by:
Pa#nr 4/17/2024
Signature: , . _ Date:
FORM: FTA 10-23 Page 5 of 5

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1% WithersRavenet
Our People.Your Success
April 24, 2024
NCDEQ APR 2 5 2024
3800 Barrett Dr.
Raleigh NC 27609
RE: The Carolinian -
Sewer Extension Application
Dear NCDEQ,
On behalf of Heritage Crossing LLC, WithersRavenel is submitting a Sewer Extension Application
for in Wilson, Wilson County, North Carolina. Please find the attached documentation in
support of a revision to approved Fast Track Application (FTA 06-21) for WQ0044900 issued on
February 8, 2024. As noted in the application, this revision is to designate a portion of the
proposed sewer as public and retain the rest of the approved as private. All flows are collected as
part of the private portion of the sewer. The proposed public segment(new permit) will have no
additional flow. The sewer proposed within this application will service 288 apartment units
inclusive of 540 bedrooms in the Heritage Crossing of City of Wilson and connects to sewer
constructed and permitted under WQCS00021.
Establishment Type(see 02T.0114(f)) Daily Design Flow'p No.of Units Flow
Apartments w/ 1 Bed 75 gal/bed 72 5.400 GPD
Apartments w/2 150 gal bed 180 27,000 GPD
Apartments w/3 225 gal/bed 36 8,100 GPD
Apartment Club House 25 gal/employee/shift 40 1000 GPD
Apartment Pool House 250 gal Plumbing Fixture 8 2000 GPD
gal GPD
Total 43,500 GPD
The proposed project will meet all of DWR's minimum design criteria for sanitary sewer
extensions as well as DWR's minimum design criteria for gravity sewers. The projected flow for
this sewer extension is 43,500 GPD. The proposed sanitary sewer lines are more than adequate
to convey the design flow rates.
The proposed project schedule is to begin as soon as the project permits have been approved.
Below is a list of items included in the application package:
1. Email with Comments
2. Sewer Extension Fast Track Application ( 5 Pages)
3. Flow Tracking for Sewer Extension Form (6 Pages)
l,)i DUutn VVIII dngLUit -DLIceL. Suite 200 ( Raleigh, NC 27601
t: 919.469.3340 1 f: 919.467.6008 1 www.withersravenel.com I License No. F-1479
Asheville I Cary I Charlotte I Greensboro I Pittsboro I Raleigh I Southern Pines I Wilmington

WithersRavenel
Our People.Your Success
4. Site Maps
a. US Topo Map (1 Page)
b. Aerial Site Map (1 Page)
Thank you for your time and efforts on this project and look forward to hearing back from you.
Please do not hesitate to contact me should you have any questions or concerns.
Sincerely,,
Ricardo Cocconcelli, PE
WithersRavenel
137 South Wilmington Street, Suite 200 1 Raleigh. NC 27601
t: 919.469.3340 J f: 919.467,6008 1 www.withersravenel.com I License No. F-1479
Asheville I Cary I Charlotte I Greensboro I Pittsboro I Raleigh I Southern Pines I Wilmington

ROY COOPER
Governor
ELIZABETH S.BISER ` �
Secretary
WILLIAM E.TOBY VINSON,JR NORTH CAROL.INA APR 2 � 2Q24
interim Director Environmental Quality
April 17, 2024
LETTER OF APPROVAL WITH MODIFICATIONS
Williams Builders of Rocky Mount, LLC
ATTN: David M. Williams
8820 Thomas Road
Rocky Mount,NC 27803
RE: Project Name: Leonard Shaffer Subdivision Phase 1
Acres Approved: 14.25
Project ID: NASH-2023-028
County: Nash
City: Rocky Mount
Address: Old Smithfield Road
River Basin: Neuse
Stream Classification: WS-III;NSW
Submitted By: Stocks Engineering, P.A.; ATTN: J. Michael Stocks, PE
Date Received by LQS: April 2, 2024
Plan Type: Revised/Residential
Dear Sir or Madam:
This office has reviewed the subject erosion and sedimentation control plan. We find the plan to
be acceptable with modifications and hereby issue this letter of Approval with Modifications. The
Modifications Required for Approval are listed on the attached page. This plan approval shall
expire three (3) years following the date of approval, if no land-disturbing activity has been
undertaken, as is required by Title 15A NCAC 4B .0129.
As of April 1, 2019, all new construction activities are required to complete and submit an
electronic Notice of Intent (eNOI) form requesting a Certificate of Coverage (COC) under the
NCG010000 Construction General Permit. After the form is reviewed and found to be complete,
you will receive a link with payment instructions for the $100 annual permit fee. After the fee
is processed,you will receive the COC via email. As the Financially Responsible Party shown on
the FRO form submitted for this project, you MUST obtain the COC prior to commencement of
any land disturbing activity. The eNOI form may be accessed at deq.nc.gov/NCGO1. Please direct
DIEEIQ—�� North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
_ Raleigh Regional Office 11628 Mail Service Center'3800 Barrett Drive I Raleigh.North Carolina 27609
� � /'� 919.79IA200

Letter of Approval with Modifications
Williams Builders of Rocky Mount, LLC
April 17, 2024
Page 2 of 4
questions about the eNOI form to the Stormwater Program staff in the Raleigh central office. If
the owner/operator of this project changes in the future, the new responsible party is required to
apply for his/her own COC.
Title 15A NCAC 4B .0118(a) and the NCGO1 permit require that the following documentation
be kept on file at the job site:
1- The approved E&SC plan as well as any approved deviation.
2. The NCGOI permit and the COC, once it is received.
3. Records of inspections made during the previous 12 months.
Also, this letter gives the notice required by G.S. 113A-61.1(a) of our right of periodic inspection
to ensure compliance with the approved plan.
North Carolina's Sedimentation Pollution Control Program is performance-oriented, requiring
protection of existing natural resources and adjoining properties. If,following the commencement
of this project, it is determined that the erosion and sedimentation control plan is inadequate to
meet the requirements of the Sedimentation Pollution Control Act of 1973 (North Carolina General
Statute 113A-51 through 66), this office may require revisions to the plan and implementation of
the revisions to ensure compliance with the Act.
Acceptance and approval of this plan is conditioned upon your compliance with Federal and State
water quality laws, regulations, and rules. In addition, local city or county ordinances or rules may
also apply to this land-disturbing activity. This approval does not supersede any other permit or
approval.
Please note that this approval is based in part on the accuracy of the information provided in the
Financial Responsibility Form,which you provided. This permit allows for a land-disturbance, as
called for on the application plan, not to exceed the approved acres. Exceeding the acreage will
be a violation of this permit and would require a revised plan and additional application fee. You
are requested to file an amended form if there is any change in the information included on the
form. In addition, it would be helpful if you notify this office of the proposed starting date for this
project. Please notify us if you plan to have a preconstruction conference.
I
E
�� North Carolina Department of Environmental Quality 1 Division of Energy.Mineral and Land Resources
_ Raleigh Regional Office 11628 Mall Service Center 13800 Barrett Drive I Raleigh.North Carolina 27609
9940w_.� 919.791.4200

Letter of Approval with Modifications
Williams Builders of Rocky Mount, LLC
April 17, 2024
Page 3 of 4
Your cooperation is appreciated.
Sincerely,
Sharan Chawla
Assistant Regional Engineer
Land Quality Section
Enclosures: Certificate of Approval
Modifications Required for Approval
NPDES NCG01 Fact Sheet
cc: Regional Office file
Stocks Engineering, P.A.; ATTN: J. Michael Stocks, PE
D North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
Raleigh Regional Office 1628 Mall Service Center;3800 Barrett Drive I Raleigh,North Carolina 27609
iH
0--Wft 919.79IA200

Letter of Approval with Modifications
Williams Builders of Rocky Mount, LLC
April 17, 2024
Page 4 of 4
MODIFICATIONS REQUIRED FOR APPROVAL
Project Name:
Project ID:
County:
1. Submit a completed Financial Responsibility/Ownership(FRO)form. Provide the location
of the land-disturbing activity accurately on the Financial Responsibility/Ownership form
in Part A, Section 2. (GS 11 3A-54.I(a))
a. The coordinates reported are for the incorrect parcel of land. Please provide an
updated FRO form with the coordinates for the correct parcel (i.e. the one that is
reported on the deed).
b. Additionally,the negative sign is missing from the reported longitude.
Ref: G.S. 113A-54.1 through G.S. 113A-57
Sections 15A NCAC 04A.0101 through 15A NCAC 04E.0504
General Permit NCG 010000 NPDES for Construction Activities
X IQ:!
North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
Raleigh Regional Office 11628 Mall Service Center 13800 Barrett Drive I Raleigh,North Carolina 27609
PA , /�o 919 791.4200

Check if this project is ARPA-funded
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 NCG01 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 approprlate'_
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. APR 2 5 2024
1. Project Name Leonard Shaffer Subdivision Phase 1 ()_Tice
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County NaSh City or Township Barley
Old Smithfield Rd. 35.785255 -7$.099
Highway/Street LatltUde(deGmal degrees) Longitud2(decima�degrees
3. Approximate date land-disturbing activity will commence. May 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 14.25
6. Amount of fee enclosed: $ 1 7 500 . 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 m No ❑
8. Person to contact should erosionand sediment control issues arise during land-disturbing activity:
Name David M. WilliamsVV E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Williams Builders of Rocky Mount, LLC 252.205.0860
Name Phone: Office # Mobile#
8820 Thomas Road 8820 Thomas Road
Current Mailing Address Current Street Address
Rocky Mount NC 27803 Rocky Mount NC 27803
City State Zip City State Zip
10. Deed Book No. 3334 Page No.460-463 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 orif the landowners)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Williams Builders of Rocky Mount, LLC [e-mail]
Company Name E-mail Address
8820 Thomas Road 8820 Thomas Road
Current Mailing Address Current Street Address
Rocky Mount NC 27803 Rocky Mount NC 27803
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile# [phone]
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.
David M . Williams Manager
Type or print name Title or Authority
'3. 2 57- Zd Z f/
Signature Date
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I, T, 1ze-g t " `V c�y,.o_t j , a Notary Public of the County of
State of North Carolina, hereby certify that 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 2r7 day of , 20
J. KEVIN VARNELL
Notary Public Nota
North arolina � f
Edgeombe County
My commission expires