NCC222028_FRO Submitted_20220531

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Thomas Bluff
2. Location of land -disturbing activity: County Harnett City or Township Erwin
Josey Williams Road-NCSR 2027 35.2681-78.7759
Highway/Street Latitude{ae«ma� degrees)Longitudeidea� degrees)
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.14
6. Amount of fee enclosed: $ 500 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed © No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dustin Blackwell E-mail [e-mail]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Weaver Homes, Inc.
Name
Phone: Offce # Mobile #
350 Wagoner Drive 350 Wagoner Drive
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville, NC 28303
City
State Zip City
State
0
10. Deed Book No. 4105 Page No. 663 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the names) of the owners) may be listed as the financially responsible party(ies).
Weaver Homes, Inc. [e-mail]
Company Name E-mail Address
350 Wagoner Drive
350 Wagoner Drive
Current Mailing Address Current Street Address
Fayetteville, NC 28303 Fayetteville, NC 28303
City State Zip City State Zip
Phone: office # 910-433-0888 Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Dustin Blackwell
Type or print name
Signature
Title or Authority
Date
I, i `01 IE5 , a Notary Public of the County of COM60IwrV
State of North Carolina, hereby certify thatUty t�11 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this Z'a day of ��� , 20_R,_
�v„A rr
z' 'NOTARY
PUBLIC �
ND CO
Notary
My commission expires,