NCC221142_FRO Submitted_20220329

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 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. Anchors Bend Ranch Lots
1. Project Name
2. Location of land -disturbing activity: Coun"NeW Hanover City or Township Harnett
Highway/Street WW & W15 NORTH BEND RD Latitude 34.2630 Longitude-77.7890
3. Approximate date land -disturbing activity will commence:ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including oft -site borrow and waste areas): 1.32
6. Amount of fee enclosed: $ N/A . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Larry Lippincott E-mail Address larry@ anchorhomesllc.com
Telephone [phone] cell # 910-821-8398 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Anchor Homes, LLC 910-821-8398 N/A
Name Telephone Fax Number
1130 Anchors Bend Way
1130 Anchors Bend Way
Current Mailing Address
Current Street Address
Wilmington NC, 28411
Wilmington NC, 28411
City State Zip
City State Zip
10. Deed Book No. 6317 & 6478 Page No. 304 & 900 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 perty.
Anchor Homes, LLC
larry@ anchorhomesllc.com
Name
E-mail Address
1130 Anchors Bend Way
1130 Anchors Bend Way
Current Mailing Address
Current Street Address
Wilmington NC, 28411
Wilmington NC, 28411
City state Zip
City State Zip
Telephone [phone]
Fax Number N/A

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
E-mail Address
Current Street Address
City State 4p 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 Certiflcate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Larry Lippincott larry@ anchorhomeslic.com
Name of Registered Agent E-mail Address
1130 Anchors Bend Way 1130 Anchors Bend Way
Current Mailing Address Current Street Address
Wilmington NC, 28411 Wilmington NC, 28411
City State zip City State Zip
Telephone [phone] Fax Number N/A
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 attomey-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.
Larry Lippincott
Type or print name
Signature
Manager
Title or Authority
3/11 /2022
Date
1, _�r�QU , a Notary Public of the County of�`/\5`W t
State of North Carolina, hereby certify that Lay f14 C,;� appeared
personally before me this day and being duly sworn hcknowlbdged that the above form was
executed by him.
Witness my hand and notarial seal, this � �'( —day of Q n j — , 20 a�
Seal
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