NCC230391_FRO Submitted_20230214

FlNANC\ALRESPONS8BNLITYIOWNERSH|P 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 Lend
Quality Geotion, 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 ieunavailable, place N/A inthe b|ank.)
Part A.
[��'O� DV��f /���� _ |D�'�� /�[��� ������ �� �%�rf'�� 1\
1. Project Name Indigo West ~ \' '^^ ^ Indian Creek Phase '^ Section '/
���UD0�/'C�� V���V��S��3
2. Location of|and-d�tudbinge���y: CountyBrunswick '^ C�yorTownohi `"
CJfT Daniels��H ��^1 �l0 -78Oz1
Highwav/G�na '"�� " ' `"= L��itudew°a��u°n��*�~�°Longi�ude(uemm�000�e*,�.
N���� �����'Df��f����POV�|
3. Approximate date land -disturbing activity vviU commence: `�' receipt ' approval
Residential
4. Purpose of development (remiden�o|, oommemia|, industrial, institutional, e�j� ' ^^~ '== " '
�
5. Tot�aoreaged�turbndoruncovanad(in�udingof�a��born��andwaateonmaa�-'��=
G. Amount offee enclosed: The application fee of$1OD.00per acre (rounded
uptothe next acre) iaassessed without eceiling amount (Exmmp|a:8.1O-acnaapplication fee ie$9OO).
Checks should bnaddressed toNCDEC>.
7. Has onerosion and sediment control plan been filed? Yes Enclosed BxZ1 No []
.3
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name R]D3|d '"ken E-mailAddres [e-mail]
�1O-�O�_OO1�
Phone: Office yNobi|e#° '° =°= =°''
0. nfRecord (attach accompanied page tolist additional ownens):
910-515_9561
- - -Nmnle - - --- - -- - - Phone: -Office #-' - —K8obika# --- - - -
6752 Parker Farm Dr., Suite 210 6752 Parker Farm Dr., Suite 210
Current Mailing Address Current Street Address
Wilmington NC 28405 VU'|m'nC]hnn NC 28405
City State Zip City State Zip
10. Deed Book No. 4960 Page No. 1040 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).
D.R. Horton, Inc.
Company Name
6752 Parker Farm Dr., Suite 210
Current Mailing Address
Wilmington NC 28405
City State Zip
Phone: Office #
[e-mail]
E-mail Address
6752 Parker Farm Dr., Suite 210
Current Street Address
Wilmington NC 28405
City State Zip
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:
Elizabeth Shelton
Name of Registered Agent
6752 Parker Farm Dr., Suite 210
Current Mailing Address
Wilmington NC 28405
City
Phone
State Zip
[e-mail]
E-mail Address
6752 Parker Farm Dr., Suite 210
Current Street Address
Wilmington NC 28405
City State Zip
Office # Mobile# [phone]
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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Phone: Office # 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.
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.
Donald Aiken
Type orpJ 4 nam
Sign
Assistant Secretary
Title or Authority
/ /(0 X� Oa
Da e
I, JLt C� ----,a Notary Public of the County of SEW +bg4bvg�
State of North Carolina, hereby certify that bE:)"A-t—Z) /-4"1 (LET--i appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness `my�ih{a� n�dand notarial seal, this �' day of 20 Z3
=JSNpTARY�
= Not
MY
COMMISS �PlRES c
Z 611rA23 Z My mmission expires 2 2 2