NCC242898_FRO Submitted_20240919

-- ANCIAL
FIN
SEDIMENTATION POBLLUITION CONTROL A T
ORM
Southern Public Works De ap rtment
140 Memorial Park Court
Pines Southern Pines, North Carolina 28387
Telephone. [phone]—Fax: [phone]
NORTH CAROI.INA
No person may initiate any land-disturbing activity greater than 1 acre(including lots or tracts of land that are a part
of a Common Plan of Development that the total disturbance will exceed 1 acre)as covered by the Town's Code of
Ordinances before this form and an acceptable erosion and sedimentation control plan have been completed and
approved by the Town of Southern Pines. (Please type or print and,if the question is not applicable or information
unavailable,place N/A in the blank.)
Part A.
1. Project Name Neff Residence
2. Location of land-disturbing activity. County: Moore City or Township Southern Pines
Street Address 4 Wicker Sham Court W
3. Latitude 35.237183 Longitude -79.424534 PIN: 857400312541
4. Percent Impervious:39%
5. Approximate date that land-disturbing activity will commence: 09.16.2024
6. Purpose of development(residential,commercial, industrial, institutional,etc.): residential
7. Total acreage disturbed or uncovered(including off-site borrow and waste areas): .31
8. Amount of fee enclosed:$
The application fee is$300.00 for the first acre plus$150.00 for each additional acre,or part thereof.
The revised plan review fee is$50 for each submittal after the 2"d review.
Any substantial revision to a previously approved,active plan is$50 per acre,or part thereof.
No Fee for Minor Construction Activities less than 1 acre of disturbance.
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lily Camina-Vick E-mail Address [e-mail]
Telephone [phone] Cell# 910 690.2249 Fax# [phone]
10. Landowner(s)of Record(attach accompanied page to list additional owners):
Thomas Neff 703 609.8919
Name Telephone Fax#
6018 Good Lion Court 6018 Good Lion Court
Current Mailing Address Current Street Address
Alexandria VA 22215 Alexandria VA 22215
City State Zip City State Zip
11. Deed Book No. 5899 Page No. 400 (Provide a copy of the most current deed).

Part B.
1, Person(s)or firm(s)who is financially responsible for the land-disturbing activity
(Provide a comprehensive list of all responsible parties on an attached sheet):
Camina Design & Construction [e-mail]
Name E-mail Address
165 Fox Hollow Court 165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax# [phone]
2. (a)If the Financially Responsible Party is not a resident of North Carolina,give name and street address
of the designated North Carolina Agent:
Name of Registered NC Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax#
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Jose' Camina [e-mail]
Name of NC Registered Agent E-mail Address
165 Fox Hollow Court 165 Fox Hollow Court
Current Mailing Address Current Street Address
Pinehurst NC 28374 Pinehurst NC 28374
City State Zip City State Zip
Telephone [phone] Fax# [phone]
,wwam

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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Lily Camina-Vick VP Design
Ty or pri ame Title or Authority
01
Sig at Date
1
1, -� c'r� a/ 441 , a Notary Public of the County of 1100 ie
State of North Carolina, hereby certify that Lil-/ V:ck
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial seal, this 3 day of Sc-/4/
i4e,-be,( , 202`I
Jeffery Markham Jk
Notary Public
Moore County, NC �/ ������aw,
My commission expires r(c„( I-t z S
Notary
Seal `�t
My commission expires ' T I. 2O?
FOR TOWN USE ONLY
Covered by 5/70 Provision: Yes❑ No❑
REVISED:January 9,2020