NCC224106_FRO Submitted_20221215

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 not applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name
Twin lakes Community - The Stockton Apartments Development
2. Location of land -disturbing activity: County Alamance City or Township Elon
0830-79.5217
Highway/Street Made Coble Drive Latitude(decimeiaegree5)36•t674-Longitude;decimaIdegrees)-1721199fl$-
3.
4.
Approximate date land -disturbing activity will commence: December 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.60 ac
6. Amount of fee enclosed, $ 600.00 . 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 Renay Welborn E-mail Address [e-mail]
Phone: Office # 336-584-5839 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lutheran Retirement Ministries 336-538-1500 336-516-3823
Name Phone: Office # Mobile #
3701 Wade Coble Drive 3701 Wade Coble Drive
Current Mailing Address
Burlington NC
City
State
Current Street Address
27215 Burlington NC 27215
Zip City
State
Zip
10. Deed Book No. 68 Page No. 177 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).
Lutheran Retirement Ministries
Pamela S. Fox, President/CEO [e-mail]
Company Name
3701 Wade Coble Drive
Current Mailing Address
E-mail Address
3701 Wade Coble Drive
Current Street Address
Burlington NC 27215 Burlington NC 27215
City State Zip City State Zip
Phone: Office # 336-538-1500 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
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 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.
Pamela S. Fox
Typeprint name
Signature
President / CEO
Title or Authority
2YatL . q i2 2
Date
I, A —,a Notary Public of the County of 816114AOIJ&Z
State of North Carolina, hereby certify that Ph o4 ela S • Fx appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my ha `d��{�rr�otarial seal, this _day of N b\JVM ber , 20Z
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