NCC230057_FRO Submitted_20230110

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 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. 1. Project Name Emerson Glen Subdivision
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3.
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Location of land -disturbing activity: CountyCabarrus City or Township Kannapolls
Highway/Street Jim Johnson Road Latitude 35027'03" Longitude 80044'47"
Approximate date land -disturbing activity will commence: Spring 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 33.97
6. Amount of fee enclosed: $ 3,400 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Cody Simoneaux E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
James M Shepherd & Andrew T Shepherd 843-900-3575
Name Telephone Fax Number
2430 Jim Johnson Road 2630 Jim Johnson Road
Current Mailing Address Current Street Address
Concord NC 28027 Concord NC 28027
City State Zip City State Zip
10. Deed Book No. 12922 Page No. 161 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.
M/1 Homes of Charlotte, LLC [e-mail]
Name
77 Center Drive Suite 100
Current Mailing Address
Charlotte NC 28217
City State Zip
Telephone [phone]
E-mail Address
77 Center Drive Suite 100
Current Street Address
Charlotte NC 28217
City State Zip
Fax Number

9. Landowner(s) of Record (attach accompanied page to list additional owners):
ITALO VILLATORO & JOSE EMERITO BAUTISTA 631-404-6521
Name Telephone Fax Number
2864 Jim Johnson Road 2864 Jim Johnson Road
Current Mailing Address Current Street Address
Concord NC 28027 Concord NC 28027
City State
10. Deed Book No. 14569
Zip City
Page No. 87
State Zip
Provide a copy of the most current deed.

9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wellington Chase Homeowners Association, Inc. [phone]
Name Telephone Fax Number
8008 Corporate Center •13Dr #10 2563 Treeline Drive
Current Mailing Address Current Street Address
Charlotte NC 28226 Concord NC 28027
City State Zip City State Zip
10. Deed Book No. 8512 Page No. 298 Provide a copy of the most current deed.

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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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:
Corporation Service Company
Name of Registered Agent
2626 Glenwood Ave Ste 550
Current Mailing Address
Raleigh NC 27608
City
State Zip
Telephone [phone]
[e-mail]
E-mail Address
2626 Glenwood Ave Ste 550
Current Street Address
Raleigh NC 27608
City State Zip
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.
VP oJ Lfo,�
Title or Authority
Date
I, LeU1--"n a Notary Public of the County ofWcOnNo
State of North Carolina, hereby certify that LD�� appeared
personally before me this day and being duly �worn acknowledged that the above form was
executed by him.
Witness my hand and notar;a(,soal„th��s
day of 20�
G A M D /V
C o JANUARY 16, z _
Notary
Seal \ "on 2025 .�
aka °e1/F oJ�J c�
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My commission expires
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