NCC222624_FRO Submitted_20220801

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 befog -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 NIA in the blank.)
Part A.Project Name Jackey's Ridge
2. Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street Heartwood Loop Rd. Latitude 34.22 Longitude -78.06
3. Approximate date land -disturbing activity will commence: 8/25/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.6
6. Amount of fee enclosed: $ . The application fee of $65,00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? YesX No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameDonald Aiken Email [e-mail]
Telephone cell # 910-508-0017 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
D.R. Horton, Inc.
910-515-9561
Name
Telephone Fax Number
131 Racine Dr., Ste. 201
131 Racine Dr., Ste. 201
Current Mailing Address
Current Street Address
Wilmington, NC 28403
Wilmington, NC 28403
City State Zip
City State Zip
10, Deed Book No. 4672 Page No. 78
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.
D.R. Horton, Inc.
[e-mail]
Name
E-mail Address
131 Racine Dr., Ste. 201
131 Racine Dr., Ste. 201
Current Mailing Address
Current Street Address
Wilmington, NC 28403
Wilmington, NC 28403
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 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 Dame. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Elizabeth Shelton [e-mail]
Name of Registered Agent E-mail Address
131 Racine Dr., Ste. 201 131 Racine Dr., Ste. 201
Current Mailing Address Current Street Address
Wilmington, NC 28403 Wilmington, NC 28403
City State zip City State Zip
Telephone[phone] 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.
Elizabeth Shelton Vice President
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prin ame Title or, uthori
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Sign t re Date
I, I ArJ i' LA -4a Notary Public of the County of AtiIJJi r�
State of North Carolina, hereby certify that LI2.Ai E i t1 S N�LTO;� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and
���notarial seal, this 15T-i
f 1J-�, Y day of JG i -T 20 at
NpTAf?V otary,
Seal
z� PUBOG � My commission expires r��y