NCC224085_FRO Submitted_20221212

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 onnbo| plan have been completed and approved by the
Land Quality Section, N.C. Department ofEnvironment and Natural Resources. (Please type orprint and, J
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
I
ProjectName Tiffany Garden
2. Location ofland-disturbing activity: County Wayne CityorTuwnahi Goldsboro
Highway/Street Central Heights Rd -Latitude 35.379 Longitude -77 918
3. Approximate date land -disturbing activity will commence: Upon issuance of permit
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0^8
8. Amount of fee enclosed: ES The application fee of $65.00 per acre (rounded
uptothe next acre) isassessed without aceiling amount (Exmmp|u:e9-aoreapplication fee is$585).
7. Has anerosion and sediment control plan been filed? Yes NoEnclosed X
8. Person bmcontact should erosion and sediment control issues arise during land -disturbing activity:
Name David L. MeDiUsP. E. E-mailAddress [e-mail]
Telephone [phone] Cell # Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owner
Southeast Investors Group, LLC 919-920-0339 j
Goldsboro NC
City State
Telephone
314 NC 111 South
27534 Goldsboro
Zip City
0[ 27534
State Zip
Page No. 184 Provide a copy of the most current deed.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing modvhy (Provide u
comprehensive list of all responsible parties on an attached sheet):
Tiffany Garden, LLC
Name E-mail Address
High Point NC 27261 High
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:
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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:
Mark Morgan [e-mail]
Name of Registered Agent E-mail Address
PO Box 16038 2408 Lake Oak Court
Current Mailing Address Current Street Address
High Point NC 27261 High Point NC 27265
City State Zip City State Zip
Mark Morgan
Type or print name
Signature
Title or Authority
767=
State of North Carolina, hereby certify that f14§4'v 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 I day of
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