NCC230873_FRO Submitted_20230329

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Arlington South - Phase 1 - Lots 5-8
2. Location of land -disturbing activity: County Cumberland City or Township Rockfish
Highway/Street Parkton Rd 34.9372-78.9625
Latltude(decimal degrees)Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2,52
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 ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ricky Nelson E-mail Address [e-mail]
Phone: Office # 910-237-1391
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Diamond Builders of Hope Mills, Inc 910-237-1391
Name
PO Box 68
Current Mailing Address
Hope Mills NC 28348
City State Zip
10. Deed Book No. 11651 Page No.
Phone: Office #
PO Box 68
Current Street Address
Hope Mills NC
city
State
910-237-1391
Mobile #
Zip
Provide a copy of the most current deed.

Part B.
� Co
°f mresponsibley(1eS) who are financially
an indivluParties on accompanied
y responsible for the land -disturbing activity (Provide a comprehensive list
O the name(s) of the ow er(s) page) if the company is a sole proprietorship or if fire landowner(s) is
(S) rnaY be fisted as the financially responsible party(es)
Diamond Builders of
Company Name Hope Mills Inc
PQ Box 68
Current Mailing Address
Hope Mills NC 28348
City
State Zip
Phone: office # 910-237-1391
[e-mail]
E-mail Address
PO Box 68
Current Street Address
Hope Mills NC 28348
City State
Mobile # [phone] Zip
Note: If the Financially Responsible Party is not the owner of the land to be di
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 Pa business re ist rtY is a domestic company registered on the NC Secretary of State
9� ry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
CRY State
Zip
Phone: Office #
E-mail Address
Current Street~
City State
Zip
Mobile #
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 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)

Continued from Items
9 & 10 in
owners. Attach copies of this
Part A of the Financial Responsibility/Ownership Form for multiple
page
as needed to list all landowners.
Landowner 2 of Record:
Charles E. Calhoun
N/A
Name
866 Sandy Bend Rd
Phone: Office # Mobile #
866 Sandy Bend Rd
Current Mailing Address
Rocky Point NC
Current Street Address
28457 Rocky Point NC 28457
City State
Zip City State Zip
Deed Book No. 10793
Page No. 420
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Deed Book No.
_ Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Deed Book No.
Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office #
Current Mailing Address
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

(c) If the Financiaily 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.
Ricky eeson
Type nt am
ignature
Owner
Title or Authority
-g lv >-�" 3
Date
I, 'in &V-0- a Notary Public of the County of S
State of North Carolina, hereby certify that Ricky Nelson appeared personally
before me this day and being duly swom acknowledged that the above form was executed by himfher.
Witness my hand and notarial seal, this i b Y day of Mri Vr'.h , 20-aLL—
Notary
My commission expires Loq I
70
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