NCC230671_FRO Submitted_20230313

FINANCIAL RESPONSIBILITWOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Cannon Park
2. Location of land -disturbing activity: County Moore City or TownshipPinehurst
Woods Road 35.2036-79.4643
Highwayl5treet Latltl[de(decima! degrees) Longitude(decirrtal degrees)
3. Approximate date land -disturbing activity will commence: January 1, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.4
6. Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark Wagner E-mail Address mwagneraa Vopmorg
Phone: Office # 910-420-1630 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Village of Pinehurst 910-295-1900
Name Phone: Office # Mobile #
395 Magnolia Road 395 Magnolia Road
Current Mailing Address
Pinehurst NC
City State
10. Deed Book No. 5745
Current Street Address
28374 Pinehurst NC 28374
Zip City State Zip
Page No. 356
Provide a copy of the most current deed.

Part B.
9. 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).
Village of Pinehurst h A Wfkk, WEW_ e VC0R�
Company Name E-mail Address
395 Magnolia Road 395 Magnolia Road
Current Mailing Address
Pinehurst NC 28374
City State Zip
Phone: Office # 910-420-1630
Current Street Address
Pinehurst NC 28374
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 E-mail Address
Current Mailing Address
City State
Phone: Office #
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if 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
Current Mailing Address
E-mail Address
Current Street Address
City 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.
Mark Wagner
Parks & Recreation Director
Type or pri t n me Title or Authority,
Signature Date
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1, n-ileACAJA h--Nx*-�n , a Notary Public of the County of 'p'
State of North Carolina, hereby certify that Mrx rr L L)G-Ane,(- appeared personally
before me this day and being duly sworn acknowledged that the bove form was executed by him/her.
Witness my hand and notarial seal, this 16 day ofWove"-e<20 a�
ElbboM A Dunn zLa"
NOTARY PUBLIC Notary
Mr -re County, NO
MyCnrwswmEVIresDemmber08,2W My commission expires c�