NCC217126_FRO Submitted_20211222

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 e-mail and/or fax
information unavailable, place N/A in the blank.)
Part A. Nelson Farms - Phase 1
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Lillington
Highway/Street Old US 421 Latitude 35.39638 Longitude -78.83917
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 31.8
6. Amount of fee enclosed: $ 2,000 + $2,080 = $4,080 The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Joseph Conlan E-mail Address [e-mail]
Telephone [phone] Cell # 269-547-3807 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mattamy Homes LLC
269-547-3807
Name
Telephone Fax Number
11000 Regency Parkway, Suite 110
11000 Regency Parkway, Suite 110
Current Mailing Address
Current Street Address
Cary NC
27518 Cary NC 27518
City State
Zip City State Zip
10. Deed Book No. 4066
Page No. 0787 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.
Joseph Conlan c/o Mattamy Homes
[e-mail]
Name
E-mail Address
11000 Regency Parkway, Suite 110
11000 Regency Parkway, Suite 110
Current Mailing Address
Current Street Address
Cary NC
27518 Cary NC 27518
City State
Zip City State Zip

Telephone Fax Number
(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
N/A
Current Mailing Address
N/A
City State
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City State Zip
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
Party is a Corporation, give name and street address of the Registered Agent:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
Telephone
State
N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City State Zip
Fax Number
N/A
(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:
The Nau Company, PLLC
Engineering Firm or other consultant
David Arnold, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
919-630-2552
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 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.
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Type or, print ame Title or Authority
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Signat a Date
a Notary Public of the County of CAJ41<45—
State of North Carolina, hereby certify that ? -Sf ✓ ��"��-"^J appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
,!eai, this oZ� day of Dlcm 20
Witness my h�tk��i
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