NCC231595_FRO Submitted_20230526

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEP 2 0 2021
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007 ‘iVinsrnn-Sa!en
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.1. Project Name Rideg emont Subdivision Phase 3 & 4
2. Location of land-disturbing activity: County Davie City or Township Mocksville
Highway/Street Whitney Road Latitude N35.903397 Longitude W80.522482
3. Approximate date land-disturbing activity will commence:9/14/2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 25.0
6. Amount of fee enclosed: $3,625.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lanny Hedrick E-mail Address [e-mail]
Telephone [phone] Cell# 336.479.6676 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Davidson Land Development, LLC 336-250-0483
Name Telephone Fax Number
5794 East Old US Highway 64 Same
Current Mailing Address Current Street Address
Lexington NC 27292 Same
City State Zip City State Zip
10. Deed Book No. Plat BK 4 Page No. 136 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 firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Davidson Land Development, LLC [e-mail]
Name E-mail Address
5794 East Old US Highway 64 Same
Current Mailing Address Current Street Address
Lexington NC 27292 Same
City State Zip City State Zip
Telephone [phone] Fax Number

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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Kennerly Engineering & Design, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Timothy S. Kennerly 336.775.2118 336.764.0797
Individual contact person (type or print) Telephone 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.
James Christopher Reid Manager
Type r print name Lit
Title or Authority
q .13. aoal
Sig ature Date
-Belinda ) Coy,O34er- , a Notary Public of the County of -L qV 105bA.
State of North Carolina, hereby certify that Jame 5 Chri5loplier 1e.\d 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 13 day of Sept , 20 a I
a__ `6 trn_
BELINDA H COVINGTON Notary
Seal
Notary Public- North Carolina My commission expires 6/6-2,k Ar✓
Davidson County
My Commission Expires Sep 26, 2025