NCC231745_FRO Submitted_20230606

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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. Blackberry Hills Subdivision
1. Project Name
activity: County Davidson Cityor TownshipThomasville
2. Location of land-disturbing
Highway/Street E US Hwy 64 NC Latitude 35.769722 Longitude -80.092500
3. Approximate date land-disturbing activity will commence: 12/01/2021
4. Purpose of development(residential, commercial, industrial, institutional. etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas).
4.1 ACRES
6. Amount of fee enclosed: $ $325 $1250 . The Express Permitting application fee is a dual
charge. The normal fee of$65.00 per acre (rounded up to the next 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David Coe Email Address [e-mail]
Telephone [phone] Cell# Fax#
9 Landowner(s)of Record (attach accompanied page to list additional owners):
Blackberry Hills, LLC 336-970-7935
Name Telephone Fax Number
3409 Union Grove Road
Current Mailing Address Current Street Address
Winston Salem NC 27127
City State Zip City State Zip
10. Deed Book No. 2511 Page No. 1119-1124 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.
Blackberry Hills, LLC [e-mail]
Name E-mail Address
3409 Union Grove Road
Current Mailing Address Current Street Address
Winston Salem NC 27127
City State Zip City State Zip

Telephone 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:
Latham-Walters Engineering, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Mitch Latham 704-895-8484
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.
r �� v /
Typ r print n me `J Title or Authdrity
Signatu V Date
I. Mar-Mai inz JAA S . a Notary Public of the County of 16AV I I,S b,-1
State of North Carolina, hereby certify that 'c N, D'\7 appeared personally
before me this day and being duly sworn acknowledged that the above for was executed by him.
Witness my hand and notarial seal, this 6 day of 716vk .! 20 0-0 0-t
C/1:4A/Y11.a..A;;%-e etteiTet—
CHARMAINE JACKSON Not
Notar �lic, North Carolina
�iiidson County �_l(�-
My Commission Expires My commission expires
March 14,2028