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Home My WebLink AboutNCC242629_FRO Submitted_20240827 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: Woodlake Country Club, Section 7, Page 19—Lot 5009 & Section 11, Page 4—Lot 5182 *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). Is Project ARPA Funded ARPA Project Name ARPA Project# No 2. Location of land-disturbing activity: County: Moore City or Township: Little River Township Highway/Street: Ginseng Drive Latitude: 35.228800 Longitude:-79.202100 3. Approximate date land-disturbing activity will commence: 9/20/2024 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.35 6. 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). 7. Has an erosion and sediment control plan been filed? No 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name: Leanna Hair E-mail Address: leannahair@onsitehomesnc.com Phone: 910-745-0001 Mobile: 9. Landowner(s)of Record: Landowner(s) of Record Name Email Business Phone Mobile Phone Nathaniel Johnson nedjohnson@onsitehomesnc.com 910-745-0001 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 2931 Fayetteville NC 28303 2931 Breezewood Fayetteville NC 28303 Breezewood Avenue, Suite 202 Avenue, Suite 202 Name Email Business Phone Mobile Phone David M. Sigmon davidsigmon@onsitehomesnc.com 910-745-0001 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 2931 Fayetteville NC 28303 2931 Breezewood Fayetteville NC 28303 Breezewood Avenue, Suite 202 Avenue, Suite 202 Name Email Business Phone Mobile Phone Onsite Homes, LLC nedjohnson@onsitehomesnc.com 910-745-0001 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 2931 Fayetteville NC 28303 2931 Breezewood Fayetteville NC 28303 Breezewood Avenue, Suite 202 Avenue, Suite 202 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). Primary Financially Responsible Party Company Name Email Business Phone Mobile Phone Onsite Homes, LLC nedjohnson@onsitehomesnc.com 910-745-0001 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 2931 Fayetteville NC 28303 2931 Fayetteville NC 28303 Breezewood Breezewood Avenue, Suite Avenue, Suite 202 202 Additional Financially Responsible Parties Company Name Email Business Phone Mobile Phone Nathaniel Johnson nedjohnson@onsitehomesnc.com 910-745-0001 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 2931 Fayetteville NC 28303 2931 Fayetteville NC 28303 Breezewood Breezewood Avenue, Suite Avenue, Suite 202 202 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: Registered Agent Information Name Email Business Phone Mobile Phone Nathaniel Johnson nedjohnson@onsitehomesnc.com 910-745-0001 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 2931 Fayetteville NC 28303 2931 Fayetteville NC 28303 Breezewood Breezewood Avenue, Suite Avenue, Suite 202 202 (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: North Carolina Agent Information Name Email Business Phone Mobile Phone Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip Engineering/Consulting Firm Information Name Email Business Phone Mobile Phone Moorman, Kizer& Reitzel, Inc. - Dennis dgilbert@mkrinc.com 9104845191 Gilbert Physical Address Mailing Address Street 1 1 City State Zip Street 1 City State Zip 115 Broadfoot Fayetteville NC 28305 115 Broadfoot Fayetteville NC 28305 Avenue Avenue Additional Details 1. Stream Classification: WS-III: Water Supply Ill 2. Was Express Review Requested: No 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.