NCC230253_FRO Submitted_20230130

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
EROSION & SEDIMENTATION CONTROL
No person may initiate any land -disturbing activity on one or more acres, '/2 acre or more inside a
watershed, as covered by the Sedimentation Pollution Control Act and the Iredell County Land
Development Code, before an acceptable erosion and sedimentation control plan has been submitted
and approved by the Iredell County Planning & Development, Erosion Control Section.
(Please type or print)
Part A.
1. Project Name Lakeshore at Windstone formerly known as Lakeshore Subdivision
/i
3.
4.
5.
6.
7.
S.
Al
Location of land -disturbing activity: County Iredell City or Township Mooresville
Highway/Street Penn Road/Lakeshore school Rd. Latitude 35.610805 Longitude -80.891378
Approximate date land -disturbing activity will commence: February 2023
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20
Amount of fee enclosed: $ N/A . An application fee of $175.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 8.10-acre application fee is $1575). For projects > than 0.5 acres but no
greater than 0.99 acres in a water supply watershed, a flat fee of $100.00 is assessed.
Has an erosion and sediment control plan been filed? Yes x No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name George Bartley Carroll E-mail Address [e-mail]
Telephone [phone] Cell # SAME Fax#
Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton, Inc. 704-620-7373
Name Telephone Fax Number
8025 Arrowridge Blvd. SAME
Current Mailing Address Current Street Address
Charlotte. NC 28273
City State Zip City State Zip
10. Deed Book No. 2971 Page No. 26-29 Provide a copy of the most current deed.
Part B.
1. Person(s) or firms) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all
responsible parties on an attached sheet):
George Bartley Carroll (D.R. Horton, Inc.) [e-mail]
Name E-mail Address
8025 Arrowridge Blvd SAME
Current Mailing Address Current Street Address
Charlotte NC 28273
City State Zip City State Zip
Telephone [phone] Fax Number __
Page 1 of 2

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
Fax Number
Zip
(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:
CT Coporation System
Name of Registered Agent
160 Mine Lake Ct
Current Mailing Address
Raleigh NC 27615
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
Current Street Address
City State
Fax Number
Zip
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 by any change in the information provided herein.
George Bartley Carroll
Typ r print na e
Sign ure
NPDES Manager
Title or Authority
1 /23/2023
Date
ILonQ1 a Notary Public of the County of JMeCXlehbN_
(� eareersonall before me this da
State of North Carolina, hereby certify that C 80%e:H � ap' Y Y
and being duly sworn acknowledged that the above orm was executell by him.
Witness my hand and notarial seal, this ?! day of Uh 20�-�
otary
Seal �' a2Do��
My commis/onxpires _
EMy
LOGAN F. CREECH
tary Public, North Carolina
Mecklenburg County
Commission Expires
March 03, 2027
Page 2 of 2