NCC221027_FRO Submitted_20220407

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. Hickory Ridge Subdivision
1. Project Name
2. Location of land -disturbing activity: County Davidson City or Township Cotton Grove Township
Highway/street Hickory Point Drive Latitude 35.6951-A7 Longitude 80.298593
3. Approximate date land -disturbing activity will commence:upon approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.1 ac
6. Amount of fee enclosed: $ Paid . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jess Meyer, CPESC, CESSWI E-mail [e-mail]
Telephone Cell # 919-215-6561 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DR Horton, Inc.
919-215-6561
Name
Telephone Fax Number
2000 Aerial Center Pkwy, Suite 110
2000 Aerial Center Pkwy, Suite 110
Current Mailing Address
Current Street Address
Morrisville NC 27560
Morrisville NC 27560
City State Zip
City State Zip
10. Deed Book No. DE 2524 Page No.2073-2075 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.
DR Horton, Inc.
[e-mail]
Name
E-mail Address
2000 Aerial Center Pkwy, Suite 110
2000 Aerial Center Pkwy, Suite 110
Current Mailing Address
Current Street Address
Morrisville NC 27560
Morrisville NC 27560
City State Zip
City State Zip
Telephone [phone]
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:
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
corrected information should there be any change in the information provided herein.
Jessica Meyer, CPESC, CESSWI NPDES Technical Compliance Administrator
Ty e or print name Title or Authority
Janma,
ature Date
I, PX.,`CTI :n&"(h a Notary Public of the County of '�i1VS l h
State of North Carolina, hereby certify that k%(CA �f� e— appeared
personally before me this day and being du s orn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of , 202-
S ELAINE HUDSPETH
Notary Public
North Carolina Notary
eal Forsyth County
My commission expires