NCC230313_FRO Submitted_20230202

Check if this project is ARPAFfunded ❑
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, ir cluding any
activity under a common plan of development of this size as covered by the NCG01 permit, bef re 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 N/A in the blank.)
Part A. I
1
Project Name Talmage Farms - Lots 1-7
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project
under which you applied for funding through the Division of Water Infrastructure (D�
2. Location of land -disturbing activity: County Robeson City or Township West Howellsville
Tolarsville Road &
Highway/Street Talmage Road Latitude(dec;ma,degrees) N34.7506° Longitude(declmaldegrees) W-78.Q
3. Approximate date land -disturbing activity will commence: January 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.36
below
6. Amount of fee enclosed: $ 400.00 . The application fee of $100.00 per acre (ro nded up to
the next acre) is assessed without a ceiling amount (Example: 8.10-acre application f e is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 7x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Stacy Simmons E-mail Address stacy _benstoutconstructi n.com
Phone: Office # 910-779-0019 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stout Timber, LLC 910-779-0019
Name Phone: Office # Mobile #
1786 Metromedical Drive Same
Current Mailing Address Current Street Address
Fayetteville NC 28304
City State Zip
Same
City State
Zip
10. Deed Book No. 2365 Page No. 734 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).
Benjamin Stout Real Estate Services Inc.
Company Name
1786 Metromedical Drive
Current Mailing Address
Fayetteville NC 28304
City State Zip
Phone: Office # 910-779-0019
brian(cDbenstoutconstruction.com
E-mail Address
Same
Current Street Address
Same _
City State Zip
Mobile #
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
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City
Mobile #
Name of Individual to Contact (it Registered Agent is a company)
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
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
hereiro.
Brian D. Walker
Type`� or print name
C WJ&W"
Signature
--------------------------------------------------------------
President
Title or Authority
t J(z1z.3
Date
O.i"1't wL L �1 Y E`E=� a Notary Public of the County of
State of North Carolina, hereby certify that Bcl fiN D LC'6l key 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 (:.Il av 20 3
�••••••r•�rrwaagMrr, / /LJ
•• s.P�' �. R�c'•�., �y
OTAR My commission expires ,fj — d '
rl► �- ;
"� 'O(JBt i