NCC232880_FRO Submitted_20231006

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 Shoaf Ridge Subdivision
2. Location of land-disturbing activity: County Davidson City or Township Lexington Township
Highway/Street Hoover Road Latitude(decimal degrees) 35.90 Longitude(decimal degrees) -80.29
3. Approximate date land-disturbing activity will commence: October, 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.6 Ac.
6. Amount of fee enclosed: $ 700.00 . 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 IX No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David Bradley Coe E-mail Address [e-mail]
Phone: Office# 336-769-4673 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Shoaf Land Development, LLC 336-240-4481
Name Phone: Office# Mobile#
6638 NC Highway 109 6638 NC Highway 109
Current Mailing Address Current Street Address
Winston-Salem NC 27107 Winston-Salem NC 27107
City State Zip City State Zip
10. Deed Book No. 2564 Page No. 779 Provide a copy of the most current deed.

Part B.
1. 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).
Shoaf Land Development, LLC [e-mail]
Company Name E-mail Address
6638 NC Highway 109 6638 NC Highway 109
Current Mailing Address Current Street Address
Winston-Salem NC 27107 Winston-Salem NC 27107
City State Zip City State Zip
Phone: Office# 336-240-4481 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:
James Frank Thomas [e-mail]
Name of Registered Agent E-mail Address
6638 NC Highway 109 6638 NC Highway 109
Current Mailing Address Current Street Address
Winston-Salem NC 27107 Winston-Salem NC 27107
City State Zip City State Zip
Phone: Office# 336-240-4481 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)

(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.
James Frank Thomas
Type or print name Title or Authority
Signature Date
, a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of , 20
Notary
My commission expires

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.
1. Project Name //ac,. uis,4,%J
2. Location of land-disturbing activity: County AV,ds-�. City or Township
Highway/Street /7/,,._',,.--/4 46 Latitude _3.5.'70 Longitude —Y� .2_G
3. Approximate date land-disturbing activity will commence: 0G—,-.),3274 2�22
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): G 6
6. Amount of fee enclosed: $ (., . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00).
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 ,ov;o Gam.- E-mail Address G"=..c.f
Telephone Cell# 3 36' g 7,, 7 1.3s' Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
: LeG- 294 . ti -f-ed'/
Name Telephone Fax Number
663=FP -4 — /'- 7 /" .
Current Mailing Address Current Street Address
4)/2 273 73 `U,NS-.., -S- ,"ter .:7/v 7
City State Zip City State Zip
10. Deed Book No. 2 E< Page No. 775 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.
Name E-mail Address
A, !3_>f :4G // 2 /0
Current Mailing Address Current Street Address
/%G 273 73 .%i S�F��.� �G 27/o�
City State Zip City State Zip
Telephone �.:45 7 C_3J 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
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.
Avr.J /j ,� ./27Gr7) cr-//rJc..o<-lcr Si�u�r= ''9 .Ucdct.�)rr�---1%
Type or print- ame Title or Authority
i
r ,' 94/23
Signature Date
I, Li e,yt, A. LeA/ 1.4-I y , a Notary Public of the County of David sign
State of North Carolina, hereby certify that David F. 6,f. 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 a t s�— day of Se ber , 20 a 3
LYNN A LEVENTRY �'
Notary Public, North Carolina Nota�
r______
Forsyth County
commission Expires
May 17, 2026 My commission expires hip.i, 17 ?v 4