NCC216818_FRO Submitted_20211209

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 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 N/A in the blank.)
Part A.
1. Project Name: Gretchen Pines Phase 4
2. Location of land -disturbing activity: County Moore City or Township Mineral Springs
Highway/Street Gretchen Road Latitude 35.2607 Longitude-79.5450
3. Approximate date land -disturbing activity will commence: November 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 12
6. Amount of fee enclosed: $780 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 $585.00).
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 Kevin Lindsay, PE Email [e-mail]
Telephone [phone] Cell # 910-920-7661 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
TKCSJM Harris LLC 910-690-1268
Name Telephone Fax Number
208 J Dowdy Road 208 J Dowdy Road
Current Mailing Address Current Street Address
Carthage NC 28327 Carthage NC 28327
City State Zip City State Zip
10. Deed Book No. 5090 Page No. 463 Provide a copy of the most current deed.
Part B.
1. 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):
TKCSJM Harris LLC [e-mail]
Name Email Address
208 J Dowdy Road
Current Mailing Address
Carthage NC 28327
City State Zip
Telephone # [phone]
208 J Dowdy Road
Current Street Address
Carthage NC 28327
City State Zip
Fax # [phone]

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
Name
Email Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone # Fax #
(b) If the Financially Responsible Parry 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:
NIA
Name of Registered Agent Email Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #
Fax #
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.
Steve Harris
Type or print name
Sig ature
Member Manager
Title or Authority
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Date
I, Y , rt 4 -L & �a__ A�., y'�-� /i? � S , a Notary Public o the County of �A 1 © 0 ZE
State of North Carolina, hereby certify that VV_ appeared personally
before me this day and being duly sworn acknowledged that the ab ve form was executed by him.
Witness my hand and notarial seal, this ©�Lday of 2021.
Notary
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