NCC221065_FRO Submitted_20220316

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
3.
4.
5.
G.
7
10
Project Name Maxwell Ridge, Phase 1 - Lots 5, 6 11 & 12
Location of land -disturbing activity: County Hoke City or Township Quewhiffle Township
Highway/Street Mildred Way Latitude N35.09140 Longitude W-79.39631,
Approximate date land -disturbing activity will commence: Februa 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.86 Acres
Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Walker E-mail Address BrianWalker anhhhomes.com
Telephone [phone] Cell # Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
H&H Constructors of Fa etteville LLC 910-486-4864 910-485-0463
Name Telephone Fax Number
3709 Raeford Road, Suite 200
Current Mailing Address
Fayetteville NC _ 28304
City State Zip
Deed Book No. 1414 Page No. 440
Same
Current Street Address
Same
City
State
Provide a copy of the most current deed.
Zip
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):
H&H Constructors of Favetteville. LLC
Name
3709 Raeford Road Suite 200
Current Mailing Address
Fayetteville NC 28304
City State Zip
Telephone [phone]
E-mail Address
Same
Current Street Address
City State Zip
FaxNumber 910-485-0463

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City
State Zip
City
Telephone Fax Number
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 by any change in the information provided herein.
Brian Walker
Type or print name
F� • Ujau.+.,. _
Signature
Division Manager & Agent
Title or Authority
'IC,
Date _
1, A-maJ L asp a- Lex-', Ve_! a Notary Public of the County of �L2 i
State of North Carolina, hereby certify that Pk 76 r) 0 I��,�Y appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
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