NCC221582_FRO Submitted_20220427

N C Department of
Environmental Quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM MAR 3 0 2022
SEDIMENTATION POLLUTION CONTROL ACT Winston-Salem
No person may initiate any land -disturbing activity on one or more acres as covered by the Act✓ Ifftte
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. Bevil Lakes Farm 11 / Wellington Ph 5 ROCKI-2020-009
1. Project Name g ( )
2. Location of land -disturbing activity: CountyROckingham City or TownshipSlmpsonvllle
Highway/StreetTyburn Trace Latitude36.246428 Longitude-79.736981
3. Approximate date land -disturbing activity will commence:4/4/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15. 1
6. Amount of fee enclosed: $ 1 ) 100 . 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? YesX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJess Meyer E-mail [e-mail]
Telephone[phone] cell # [phone] Fax #
91
Landowner(s) of Record (attach accompanied page to list additional owners):
DR Horton, Inc. [phone]
Name Telephone
2000 Aerial Center Parkway, Suite 110A (same as mailing
Current Mailing Address Current Street Address
Morrisville NC 27560
Fax Number
City State Zip City State Zip
10. Deed Book No. 1611 Page No. 1 352 Provide a copy of the most current deed.
Part B. (Rockingham)
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 Parkway, Suite 110A (same as mailing)
Current Mailing Address Current Street Address
Morrisville NC 27560
City State Zip
Telephone[phone]
City State Zip
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
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 State Zip
Telephone
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.
Type or print name Title or Authority
' �� M- , �Y
Stignature ��� Date
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I, a Notary Public of the County of 5
(�NO:5n
State of North Carolina, hereby certify that &z6SCC.A Affe appeared
personally before me this day and being my sworn acknowledged that the above form was
executed by him. MX6
Witness my hand and notarial seal, this �q day of — 2
S. ELAINE HUDSPETH
Notary Public
North Carolina ary
Forsyth County
My commission expires ( u ` z—