NCC221434_FRO Submitted_20220412

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 Duality 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. Preston Oaks
I . Project Name
2. Location of land -disturbing activity: County_ tokes City or Township King
Highway/Street Old US 52 Latitude 36* 1718" Longitude 80*22' 13"
3. Approximate date land -disturbing activity will commence, 1131 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14. 75
17500.00 . The application fee of $100.00 per acre
6. Amount of fee enclosed: $ PP �
(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 Adam Stewart E-mail [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Preston Oaks King, LLC 336-462-3421
Name Telephone Fax Number
1239 S Friendship Rd
1239 S Friendship Rd
Current Mailing Address
Current Street Address
Germanton NC
27019 Germanton NC, 27019
city State
Zip City State Zip
10. Deed Book No. 745
Page No.1281 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.) ff the company or irrm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
Preston Oaks King, LLC
[e-mail]
Name
E-mail Address
1239 S Friendship Rd
1239 S Friendship Rd
Current Mailing Address
Current Street Address
Germanton NC
27019 Germanton NC 27019
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
Fax Number
State Zip
(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.
Adam Stewart
Ty r rint nam
Signature
Owner
Title or Authority
_/- 3-2�2�
Date
I, 1 1 J S�f a Notary Public of the County of --sic 5
State of North Carolina, hereby certify that adorn )IeU2 o appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness mX,,��Apd notarial seal,
let
�r
this 3
rctday of c , 20_� C�
mlai I
Notary
My commission expires