NCC220591_FRO Submitted_20220202

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. Summerlyn Village
1. Project Name. - —
2. Location of land -disturbing activity: County Cabarrus City or Township,Kannapolls
Highway/Street Mooresville Road Latitude 35.488271 Longitude-80.659395
3. Approximate date land -disturbing activity will commence: May 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_97.00
6. Amount of fee enclosed: $ 6,305.00 . 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 Dacus E-mail Address [e-mail]
Telephone,704-200-4775 cell # 704-200-4775 Fax # .
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Summerlyn Partners, LLC
Name Telephone Fax Number
3840 Windermere PKWY Suite 402
Current Mailing Address Current Street Address
Cumming, GA 30041
City State Zip City State Zip
10. Deed Book No_ 11199 Page No. 140 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Hoopaugh Grading [e-mail]
Name
303 Forsyth Hall Drive
Current Mailing Address
Charlotte, NC 28273
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City State
Fax Number
Zip

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:
Keith Dacus [e-mail]
Name
1410 Chalmers Ct
Current Mailing Address
Concord, NC 28027
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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
corr ed information should there be any change in the information provided herein."�\ b, �Le'q. III
Type o Title or Aut ority
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Signature Date
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a Notary Public of the County of Vors_kL
State of Nlorft56F�, hereby ertify that � +r . a��� appeared
personally before me this day and being duly sworn acknowledged at the above form was
executed by him.
Witness my hand and notarial seal, this q day of u ss�t , 20 a1
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