NCC243604_FRO Submitted_20241120

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 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 and/
or fax information unavailable, place N/A in the blank.)
P1.art AProject Name Needham Estates
2. Location of land-disturbing activity: CountyAlamanCe City or Township Haw River
Highway/Street Phillips Chapel Rd Latitude 35.9892 -79.3089
Longitude
3. Approximate date land-disturbing activity will commence: 1 1/01/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.27
6. Amount of fee enclosed: $ 800.00 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bill Boone E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Phillips Chapel Development, LLC 336-404-9113
Name Telephone Fax Number
1141 Jay Ln 1141 Jay Ln.
Current Mailing Address Current Street Address
Graham, NC 27253 Graham, NC 27253
City State Zip City State Zip
10. Deed Book No. 067 Page No.0151 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Phillips Chapel Development, LLC [e-mail]
Name E-mail Address
1141 Jay Ln 1141 Jay Ln
Current Mailing Address Current Street Address
Graham, NC 27253 Graham, NC 27253
city state Zip City state Zip
Telephone [phone]
Fax Number

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:
•
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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 sianed 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 witn
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.
ki SO-//.2dirr /11(ALCSe_17—
Type or print name Title or Authority
Signature Date
I, at v3 C9 K a Notary Public of the County of X(
#el-g K c ,C
State of North Carolina, hereby certify that 2, S 1? ecay..¢J1
ared
personally before me this day and being duly sworn acknowledged that the above forme was
executed by him.
G
Witness my hand and notarial seal. this / l/ t
O day of �o Ved.. 9n 2.Y
DAVID K WHITFIELD Notary
Not y P_y�blic, North Carolina
` 01mance County
My Commission Expires
January 13,2027 My commission expires /" 2-02-7