NCC230996_FRO Submitted_20230414

DocuSign Envelope ID:0970F3C4-0A8F-43C8-8578-2FE2FA9D4671
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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Glen Oaks Phase 2 Lot Erosion Plan
1. Project Name
2. Location of land-disturbing activity: County Davidson City or Township Lexington
Highway/Street Glenoaks Drive Latitude35.816764 Longitude-80.274416
3. Approximate date land-disturbing activity will commence:Aug 9, 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2
6. Amount of fee enclosed. $130 The application fee of$65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
7 Has an erosion and sediment control plan been filed? Yes No Enclosed X
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David Harr E-mail Address [e-mail]
Telephone Cell# 336-314-0974 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
WJH LLC
Name Telephone Fax Number
3091 Governors Lake DR, STE 300
Current Mailing Address Current Street Address
Norcross NC 30071
City State Zip City State Zip
10. Deed Book No. 2462 Page No. 1955-1971 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or fi►rn is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Dave Hodgman [e-mail]
Name E-mail Address
1225 Eastchester Dr 1225 Eastchester Dr
Current Mailing Address Current Street Address
Highpoint, NC 27265 Highpoint, NC 27265
City State Zip City State Zip
Telephone [phone] Fax Number

DocuSign Envelope ID:0970F3C4-0A8F-43C8-8578-2FE2FA9D4671
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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:
Dave Hodgman [e-mail]
Name of Registered Agent E-mail Address
1225 Eastchester Dr 1225 Eastchester Dr
Current Mailing Address Current Street Address
Highpoint, NC 27265 Highpoint, NC 27265
City State Zip City State Zip
Telephone [phone] Fax Number
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 be any change in the information provided herein.
Dave Hodgman Regional President
Type or print name�Docusignedby: Title or Authority
Voum, pair 6/24/2021
' — 7o347aTB4 E...
Signature Date
Teddi Tate Carr , a Notary Public of the County of Guilford
State of North Carolina, hereby certify that Dave Hodgman appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 24th day of June 20 21
DocuSigned by:
TEDDI TATE CARR
Electronic Notary Public Notar 757B2769AFDF424..
Seal Guilford County
North Carolina My commission expires 7/14/2023
Commission Expires 7/14/2023