NCC233492_FRO Submitted_20231127

Check if this project is ARPA-funded
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Riverwalk of Hayesville
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name or Project
Number(e.g.. SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Clay City or Township Hayesville
Highway/Street Riverwalk Circle Latitude(deci l degrees) 35.048 Longitude(decin I degrees) 83.814
3. Approximate date land-disturbing activity will commence: 8/1/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.48
6. Amount of fee enclosed: $ 200.00 . 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 11 Enclosed No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Tighe White E-mail Address [e-mail]
Phone: Office# 828-389-8102 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Riverwalk of Hayesville,LLC. 828-389-8102 828-361-1232
Name Phone: Office# Mobile#
68 Winchester Cove Rd 68 Winchester Cove Rd
Current Mailing Address Current Street Address
Hayesville NC 28904 Hayesville NC 28904
City State Zip City State Zip
10. Deed Book No. 302 Page No. 239 Provide a copy of the most current deed.
1

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).
Riverwalk of Hayesville,LLC. [e-mail]
Company Name E-mail Address
68 Winchester Cove Rd 68 Winchester Cove Rd
Current Mailing Address Current Street Address
Hayesville NC 28904 Hayesville NC 28904
City State Zip City State Zip
Phone: Office# 828-361-1232 Mobile# [phone]
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:
Tighe White [e-mail]
Name of Registered Agent E-mail Address
68 Winchester Cove Rd 68 Winchester Cove Rd
Current Mailing Address Current Street Address
Hayesville NC 28904 Hayesville NC 28904
City State Zip City State Zip
Phone: Office# 828-361-1232 Mobile# [phone]
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
Name of Individual to Contact(if Registered Agent is a company)
2

(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.
N/A
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.
Tighe White Managing Member
Type or print name Title or Authorit
Signatu Date
I, AJvt t {L e ,, a Notary Public of the County of CI
State of North Carolina,hereby certify that II I Qlrtt- w appeared personally
before me this day and being duly sworn ackno edged that the above
� /form was executed by him/her.
C6-112
Witness my hand and notarial seal, this day of OV &k X , 20 2�
i 9 APRIL L KRIEGER
Notary Public, North Carolina
Clay County Notary
My Commission Expires
My commission expires 0� u0 '2:7

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Riverwalk of Hayesville Property Owners Association,Inc. 828-389-8102 828-361-1232
Name Phone: Office# Mobile#
68 Winchester Cove Rd 68 Winchester Cove Rd
Current Mailing Address Current Street Address
Hayesville NC 28904 Hayesville NC 28904
City State Zip City State Zip
Deed Book No. 321 Page No. 183 Provide a copy of the most current deed.

Rivenvalk of Hayesville Property Owners Association, Inc.
68 Winchester Cove Road
Hayesville NC 28904
October 11, 2023
Rivenvalk of Hayesville, LLC.
68 Winchester Cove Road
Hayesville NC 28904
Re: Rivenvalk of Hayesville Subdivision
Clay County
To whom it may concern,
This letter gives"Riverwalk of Hayesville, LLC" authority to pursue plan approvals for erosion
and sediment control plans for"Rivenvalk of Hayesville Subdivision"located in Hayesville NC. We also
give per ission for"Rivenvalk of Hayesville, LI.C"to perform construction on this property.
4C
V
Tighe White October 11, 2023
Registered Agent
I, g(kiAkAai1y. (,SIC , a Notary Public of the County of eA
State of North Carolina, hereby certify that t\(le WPM 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 1 ttt" day of O r Ar , 20 '13
Notary
Scat .`` 1 AR YN /1i
iviv commission expires '0[ L7.1-- ?\Notary Public �fc
Cherokee
County
My Comm. Exp.
,L 05-19-2027
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