NCC220637_FRO Submitted_20220204

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FINANCIAL RESPONSIBI J�N
SEDIMENTATION POLLUTION ONR ROL ACT 2Q ��
gY
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before
form and an acceptable erosion and sedimentation control plan have been completed and approvedhis_
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 NIA in the blank.)
Part A. M
I. Project Name Meridian Forest
2. Location of land -disturbing activity. County Brunswick City or Township Bolivia
Highway/Street Off of Hwy 211
Latitude Longitude
3. Approximate date land -disturbing activity will commence: 2/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 22,81
8. Amount of fee enclosed: $ The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Donald Aiken E-mail Address [e-mail]
Telephone cell # 910-508-0017
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton, Inc. 919-515-9561
Name Telephone
4049 Belle Terre Blvd. Fax Number
4049 Belle Terre Blvd.
Current Mailing Address
Current Street Address
Myrtle Beach SC 27597 Myrtle Beach SC 27597
City State Zip City
State zip
10. Deed Book No. 4772 Page No. 301
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.
D.R. Horton, Inc. [e-mail]
Name E-mail Address
131 Racine Dr., Suite 201 131 Racine Dr., Suite 201
Current Mailing Address Current Street Address
Wilmington NC 28403 Wilmington NC 28403
City State Zip City State
Telephone
919-515-9561 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:
Elizabeth Shelton
Name of Registered Agent
131 Racine Dr., Suite 201
Current Mailing Address
Wilmington
City
NC 28403
State
Telephone [phone]
[e-mail]
E-mail Address
131 Racine Dr., Suite 201
Current Street Address
Wilmington NC
Zip City
Fax Number
28403
State Zip
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.
Donald Aiken
Assistant Secretary
Type or print Title or Authority
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I, C -F- , a Notary Public of the County of aiz_W N16jW(5e_
State of North Carolina, hereby certify that 00,�d_ 7t i&gJ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my
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