NCC222302_FRO Submitted_20220624

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 N/A in the blank.)
Part A.
1. Project Name Lot 29 @ Pennington @ Jordan Lake
2. Location of land -disturbing activity: CountyChatharll City or Township PittSbOrO
Highway/Street62 N. Julip Court Latitude(decimal degrees) 35.738 Long itu d e(dedmal degrees) -79.064
3. Approximate date land -disturbing activity will commence: June 20, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '08085
6. Amount of fee enclosed: $1 0�aceiling
The application fee of $100.00 per acre (rounded
up to the next acre) is assessemount (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 ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name SCOtt Barnes
Phone: Office # N/A
E-mail Address [e-mail]
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
W.T. Barker Construction
Name
1401-113 Sunday Drive
Current Mailing Address
Raleigh NC 27607
City State Zip
Phone: Office #
919-625-5617
Mobile #
1401-113 Sunday Drive
current Street Address
Raleigh NC 27607
City State Zip
10. Deed Book No. 02216 Pa a No. 0814
9 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 name(s) of the owner(s) may be listed as the financially responsible party(ies).
W.T. Barker Construction Company
Company Name
1401-113 Sunday Drive
Current Mailing Address
Raleigh NC 27607
City State Zip
Phone: Office #
[e-mail]
t-mail Address
1401-113 Sunday Drive
current Street Address
Raleigh NC 27607
Ulty State Zip
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
t-mail Address
Current Mailing Address Current Street Address
City State
Phone: Office #
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
nl�--
Current Mailing Address
City
Deed Book No.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
Current Mailing Address
City State
Deed Book No.
Landowner 4 of Record:
N
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. Provide a copy of the most current deed.
came Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 4 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #

(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
William Barker
Type r prin e
Signature
Vice President
Title or Authority
6/9/22
Date
-------------------
I, 'P a Notary Public of the County of
State of North Carolina, hereby certify that �,j'�,/��j� 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 day of,20,�?J_
9M
STACY A WACHTEL
f^ Notary Public, North Carolina
Wake County
My Commission Expires
o ary
My commission expires