NCC216335_FRO Submitted_20211116

. 11 an -FL ue GUYIIUnMCntW t,&Btlty
JUN 16 2021
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT Raleigh Regional Office
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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
Project Name Woodlief Subdivision - Phase 3 & 4
2. Location of land -disturbing activity: County Franklin City or Township Youngsville
Highway/Street -Long Rd Latitude 36°04'18.28" Longitude 78130'07.29"
3. Approximate date land -disturbing activity will commence: Winter 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.5 AC
6. Amount of fee enclosed: $ 455 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kristi Dillard E-mail Address [e-mail]^
Telephone [phone] Cell # N/A Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Andy_S. Woodlief & Crystal S. Woodlief N:'A
Name Telephone
1306 Long Mill Rd. 1306 Long Mill Rd.
Current Mailing Address Current Street Address
NA
Fax Number
Youngsville NC 27596 Youngsville NC 27596
City State Zip City State Zip
10. Deed Book No. 1214 Page No. 124 Provide a copy of the most current deed.
(See Attached)
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Dan Ryan Builders - North Carolina, LLC
Name
E-mail Address
3000 RDU Center Drive, Suite 202 (Same)
Current Mailing Address Current Street Address
Morrisville NC 27560 Same
City 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:
N/A NIA
Name
E-mail Address
N/A NIA
Current Mailing Address Current Street Address
N/A N/A N/A NIA N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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
Parry is a Corporation, give name and street address of the Registered Agent:
NIA NIA
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
NZA_ __ __ N/A N/A N/A N/A _ N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
C ky C - � Viez — A
Type or print name Title or Authority
v ,C' �- I
n e Dat T
I, At'1'ta %4o, L • }`�U-'"�-'�ne-Z-- , a Notary Public of the County of oL-f
State of North Carolina, hereby certify that _ a-, 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 )� day of J20 0-1
n. k
AMANDA L MARTINEZ Notary
Notary Public, North Carolina
W^Wtounty
My Commission Expires My commission expires_i3
August13,2024

9. (Continued)
Landowner(s) of Record (attach accompanied page to list additional owners):
Crystal Star Woodlief N/A N/A
Name Telephone Fax Number
1352 Long Mill Rd. PO Box 19
Current Mailing Address Current Street Address
Youngsville NC 27596 Young_sville NC 27596
City State Zip City State Zip
10. Deed Book No. 1986 Page No. 327 Provide a copy of the most current deed.
(See Attached)