NCC243425_FRO Submitted_20241105

Check if this project is ARPA-funded 0
Attach a copy of the Letter of Intent to Fund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturb ng 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 10 the appropriate
Regional Office. (Please type or print and, if the question is riot applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Highway 109 Subdivision
`lf 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. Locator of land-disturbing activity: County Davidson City or Township Denton
Highway/StreeiGarnej Road Latitude,dearnaieegreasr35.t;54d79 Longitudevmemarde 9>�O.tOt�a9
3. Approximate date land-disturbing activity will commence: 11r/1/20
4. Purpose of development(residential,commercial,industrial, institutional.etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 14.00
6. Amount of fee enclosed: $1,400 . 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:
NameJef#rey Todd Yates E-mail [e-mail]
Phone office# 336-240-1393 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Jeffrey T Yates 336-240-1393 336-240-1393
Name Phone: Office# Mobile#
PO Box 1625 2579 E US Hwy 64
Current Mailing Address Current Street Address
Lexington, NC 27293 Lexington, NC 27292
C ty State Zip City State Zip
0. Deed Book No.2009 Page No,288 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 names)of the owner(s)may be listed as the financially responsible party(ies).
Asher Heights, LLC [e-mail]
Company Name E-mail Address
2579 E US Highway 64 2579 E US Highway 64
Current Mailing Address Current Street Address
Lexington, NC 27282 Lexington, NC 27282
City State Zip City State Zip
Phone: Office#336-240-1393 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:
Jeffrey Todd Yates [e-mail]
Name of Registered Agent E-mail Address
2579 US Highway 64 East 2579 US Highway 64 East
Current Mailing Address Current Street Address
Lexington, NC 27282 Lexington, NC 27282
City State Zip City State Zip
Phone: Office# 336-240-1393 Mobile# [phone]
Jeffrey Todd Yates
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 Stale Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

c; !f the Financially Responsible Party is engaging in business under an assumed name,give name under
,v lich 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
':trove information is true and correct to the best of my knowledge and belief and was provided
y r';ti- under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
his r,ttorney-in-fact. or if not an individual, by an officer, director, partner, or registered agent with
ihi r ithor ty to execute instruments for the Financially Responsible Party)_ I agree to provide
cDrreL ted information should there be any change in the information provided herein.
Jeffrey Todd Yates President/Managing Member
-type. print nen Title or Authority
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fnatu Date
I.. ` zu��—��4a «tC _, a Notary Public of the County of ^_ ) A C . )Y\ i
„f;of Nc b Carolna, hereby certify that 144 j24e , appeared personally
be'-rr¢ me this day and being duly sworn acknowledged at the above form was executed by hire/her.
l'Pi : s ss :-,y hand and notarial seal, this 19 day of c �. X} . , 20 ?(
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JEFFERY TODD YATES 7794
NCOEQ 9/19/2024
1,400.00
FIRST BANK-PERSO 1,400.00