NCC215415_FRO Submitted_20210930

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 a -mail and/or fax
information unavailable, place NIA in the blank.)
Part A.
1. Project Name Tillery Tradition Area 7
Location of land -disturbing activity: County. Montgomery City or Township Mount Gilead
Highway/Street Tradition Drive
Latitude 35.28551 Longitude-80.08018
3. Approximate date land -disturbing activity will commence: 10/112021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 27.15
6. Amount of fee enclosed: $ 3 820.00 . The Express Permitting application fee is a dual
$6
charge. The normal fee of 5.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $260.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example. 9 acres total is $2,585).
7. Has an erosion and sediment control plan been filed? Yes_ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nathan Russell E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tillery Tradition INC. 704 984-1650 NIA
Name Telephone Fax Number
1721 US Hwy 52 N Same
Current Mailing Address Current Street Address
Albemarle NC 28001 Same
City State zip City State Zip
10. Deed Book No. 343 Page No. 453 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.
Pee Dee Land Development nrussell nlr rou inc.com
Name E-mail Address
37938 US Hwy 52 N
Current Mailing Address
New London NC 28217
City
Same
Current Street Address
Same _ Same
State Zip City
State
Zip

Telephone [phone] Fax Number NIA
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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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:
Nathan Russell
Name of Registered Agent
37938 US Hwy 52 N
Current Mailing Address
New London NC 28217
City State zip
Telephone. [phone]
nrussell njrgroupinc.com
E-mail Address
Same
Current Street Address
Same Same
City State zip
Fax Number NIA
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
R. Joe Harris & Associates
Engineering Firm or other consultant
Patrick Murphy
Individual contact person (type or print)
pmurphy(a rjoeharris.com
E-mail Address
803 802-1799
Telephone
NIA
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 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.
Nathaniel J Russell Member
Type or print n We Title or Authority
/ 8-9-21
Si atur - pate
a Notary Public of the County of 1
State of North Carolina, hereby certify that Vss appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
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