NCC220870_FRO Submitted_20220315

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.
1. Project Name Caroline's Way
2. Location of land -disturbing activity: County Wilson City or Township Wilson
Highway/Street Caroline's Way Latitude 35.647 Longitude-77.967
3. Approximate date land -disturbing activity will commence: January 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 acres
Previous Check Total
6. Amount of fee enclosed: $ 770 + $1,430 = $2,200 . The application fee of $100.00 per acre (rounded
up to the next hole acre) is assessed without a ceiling amount (e.g. an 8.2-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jessica Meyer E-mail Address [e-mail]
Telephone [phone] Cell # 919-215-6561 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Williams Builders of Rocky Mount, LLC
Name Telephone Fax Number
8820 Thomas Road 8820 Thomas Road
Current Mailing Address Current Street Address
Rocky Mount NC 27803 Vicky Mount NC 27803
City State Zip City State Zip
10. Deed Book No. 2928 Page No. 103 Provide a copy of the most current deed.
Part B.
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. JAMeyer(a-)-drhorton.com
Name E-mail Address
2000 Aerial Center Parkway, Suite 110A 2000 Aerial Center Parkway, Suite 110A
Current Mailing Address Current Street Address
Morrisville NC 27560 Morrisville NC 27560
City State Zip City State Zip
Telephone [phone] Fax Number 1-800-718-8204

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:
Name of Registered Agent
Current Mailing Address
City State
Telepho
E-mail Address
Current Street Address
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
corrected information should there be any change in the information provided herein.
dC5S'1LA �•I ,STP cyym Cd I Ca✓ICJVQKU
T t name Title or Authority
g ature Date
a Notary Public of the County of 5
State of North Carolina, hereby certify that kc�c'(C_A ✓lam appeared
personally before me this day and being duly s acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this � ✓ d;
S ELAINE HUDSPETH
Seal Notary Public
North Carolina
Forsyth County
My commission expires �� �2Z-