NCC222975_FRO Submitted_20220819

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 riot applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name3210 Silk Hope Lindley Mill road, Snow Camp, NC 27349
2. Location of land -disturbing activity: County Chatham City or Township Snow Camp
HI g hwa /Street 3210 Silk Hope Lindley Milt Rd 35.8251 _79.3545
y Latltude[dearnal degrees] Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: 8/22/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.), Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4,90
B. 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 p Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Stephanie McArthur E-mail Address [e-mail]
Phone: office # Mobile # [phone]D55
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stephen Lask
Name
239 Kidds Ridge
Current Mailing Address
Siler City NC 27344
City State
10. Deed Book No. 1036
Phone: Office #
239 Kidds Ridge
Current Street Address
Siler City NC 27344
Llp City
Page No. 525
State
919-842-6336
Mobile #
Zip
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 iandowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Stephen and Samantha Lask, Stephanie McArthur [e-mail]
Company Name E-mail Address
239 Kidds Ridge 239 Kidds Ridge
Current Mailing Address
Siler City NC 27344
City state
Phone: Office #
Current Street Address
Siler City NC 27344
Zip City State
Mobile # [phone]
Zip
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 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)
(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)

(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 Dame.
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 individuaI(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.
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l a Notary Public of the County of
State of North Carolina, hereby certify that LL 4 appeared personally
before me this day and being duly sworn acknow edged that the above form was executed by him/her.
Witness my hand and notarial sea[, this __ aday of
ICt13IMM 1-+vDf ,Z►�!'N otarY
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" i.�`�;?1W My commission expires ,V-11Y

Continued from Items 9 & 90 in Part A of the Financial Respon sibilitylO wnership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Samantha Lask
772-341-3646
Name
Phone: Office # Mobile #
239 Kidds Ridge
239 Kidds Ridge
Current Mailing Address
Current Street Address
Siler City NC 27344
Siler City NC 27344
City State
Zip City State Zip
Deed Book No.1036
Page No. 525 Provide a copy of the most current deed.
Landowner 3 of Record:
Stephanie McArthur
919-810-2055
Name
Phone: Office # Mobile #
239 Kidds Ridge
239 Kidds Ridge
Current Mailing Address
Current Street Address
Siler City NC 27344
Siler City NC 27344
City State
Zip City State Zip
Deed Book No. 1036
Page No. 525 Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Deed Book No.
Page No.--- Provide a cony of the mnct ri irront ripori
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No.
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.

E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Continued from Item 1 in Part B of the Financial Responsibilitylownersh►p Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
Company 3 Name
Current Mailing Address
Company 4 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State zip
State Zip
State Zip