NCC233023_FRO Submitted_20231009

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 Environment and Natural Resources. (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 Waterside Townhomes
2. Location of land-disturbing activity: County Fender City or Township Surf City
Highway/Street Nc s0/Nc 210/Roland Ave. Latitude 34a 27'3 .71"N Longitude 77°33'34.22"W
3. Approximate date land-disturbing activity will commence: March 19, 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.5
6. Amount of fee enclosed: $ 595 19 AC x $65) . 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 N
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Patrick Wahl E-mail Address PWahl®drhorton.com
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SFTEN, LLC
Name Telephone Fax Number
160 Mine Lake Ct. , Suite 200 (Same as mailing)
Current Mailing Address Current Street Address
Raleigh NC 27615 (Same as mailing)
City State Zip City State Zip
10. Deed Book No. 4694 Page No. 1594-1599 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
SFTEN, LLC
Name E-mail Address
160 Mine Lake Ct. , Suite 200 (Same as mailing)
Current Mailing Address Current Street Address
Raleigh NC 27615 (Same as mailing)
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:
N/A
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:
Elizabeth Shelton elsheltonfidrhorton.com
Name of Registered Agent E-mail Address
160 Mine Lake Ct. , Suite 200 (Same as mailing)
Current Mailing Address Current Street Address
Raleigh NC 27615 (Same as mailing)
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.
Elizabeth Shelton Vice President
Type or rin name Titl or Authority
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Signature Da e
I, kIJ ELI . C.ft"( , a Notary Public of the County of AO 4A/JeufR
State of North Carolina, hereby certify that Elizabeth Shelton 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 Ail day of 1E(3?-✓AV"t , 20A 1
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