NCC224152_FRO Submitted_20221220

NC Department of
Environmental Quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM ��� Q ���Z
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION Winston-Salern
No person may initiate any land -disturbing activity on one or more acres as covered by the AJNW bnit ig'fWV
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. In -V 6 , 2-6-2-3 --M�� ( 4/ is
Project Name Fieldstone Subdivision Phase 1
2. Location of land -disturbing activity: County Davidson
City or TownshlpArcadia
Highway/Street South Union Grove Road Latltude(decimal degrees) 35.9578 Long ltude(decimaldegrees) 80.2689
Approximate date land -disturbing activity will commence: 12/31/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed 3200 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). 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 Will Derrickson E-mail Add resswderrickson(a)mungo.com
Phone: Office # 336-979-4054 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Palmetto Land Investors, LLC 336-979-4054
Name Phone: Office # Mobile #
441 Western Lane SAME
Current Mailing Address Current Street Address
Irmo SC 29063 SAME SAME SAME
City State Zip City State Zip
10. Deed Book No.2523 Page No.1117 Provide a copy of the most current deed.
G

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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Clayton Properties Group, INC. wderricksonCcilmungo.com
Company Name E-mail Address
221 Jonestown Road SAME
Current Mailing Address Current Street Address
Winston Salem NC 27105 SAME SAME SAME
City State Zip City State Zip
Phone: Office # 336-979-4054 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:
Will Derrickson
Name of Registered Agent
221 Jonestown Road
Current Mailing Address
Winston Salem NC
City State
Phone: Office # 336-979-4054
wderrickson(&mungo. com
E-mail Address
SAME
Current Street Address
27105 SAME
Zip City
Mobile # [phone]
Will Derrickson
Name of Individual to Contact (if Registered Agent is a company)
SAME SAME
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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
Shugart Homes
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
FEI Consulting
Engineering firm or other consultant
Brent Nesom
Individual contact person (type or print)
bnesom(q)_feiconsulting.com
E-mail Address
336-544-6421 NA
Phone: Office # Mobile #
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.
Will Derrickson
Type or ' t name
S nature
Agent
Title or Authority
f;)IstP-;—
Date
I, (�i r, ,t_ A a Notary Public of the County of ('ra U'i A SOY-,
State of North Carolina, hereby certify thatj_a mPs 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 Dt!�'C_ 20�
CO E A. ADER
C
NOTARY PUBLI
DavidsoCarolina
ounty
North
M mission ires 04/05/2025
Notary
My commission expires `����