NCC216569_FRO Submitted_20211123

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.)
Part A. The Glenns
1. Project Name
The
Location of land -disturbing activity: County union County City or Township Wingate
Highway/Street Ans©nvl lle Dr Latitude 34.998611 Longitude 86.422222
3. Approximate date land -disturbing activity will commence: Dec 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 37.95 rac
6. Amount of fee enclosed: $ 21470 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Keith Fenn E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
B & C Land Farming, LLC
Name Telephone Fax Number
2627 Brekonridge Centre Dr #103
Current Mailing Address Current Street Address
Monroe, NC 28110
City State Zip City State Zip
10. Deed Book No. 6594 Page No. 13 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.
Carolina Development Services, LLC [e-mail]
Name E-mail Address
2627 Brekonridge Centre Dr Suite 101
Current Mailing Address
Monroe, NC 28110
City State
Telephone [phone]
Current Street Address
Zip City State Zip
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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Wesley S. Hinson
Name of Registered Agent
309 Post Office Dr.
Current Mailing Address
Indian Trail NC 28079
City State Zip
704-774-1964
Telephone
[e-mail]
E-mail Address
Current Street Address
City State Zip
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.
G. David Cuthbertson
Type or print na ,
�----
Signature
Manager
Title or Authority
2/25/21
Date
I,�TZ� �r2 SS a Notary Public of the County of Lkv\i c�
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my han and notarial seal,
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= Seal
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this D �S day of 20 � k
Notary
My commission expires 3` Z-`('- o -a-S