NCC240056_FRO Submitted_20240109

Check if this project is ARPA-funded ❑
FINANCIAL RESPO NSIBILITY/O W PERSHIP FO RVI
SEDIM ENTATIO NPO LLUTIO NCO NMRO LACT
No person m air initiate any land-disturbing activity on one or m ore acres as covered by the Act, including any
activity under a corn m an plan of development of this size as covered by the NCG 01 perm t, before this form
and an acceptable erosion and sedim entation control plan have been completed and approved by the Land
Q uality Section, N.C. Departm ent of Environm ental Q uality. Subm L the corn pleted form to the appropriate
Regional O fice. (Please type or print and, if the question is not applicable or the e-m al address or phone
num her is unavailable, place N/A in the blank.)
Part A.
1. Project Nam eBLAKE FARM - PARCEL H
*If this project involves Am a-ican Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County FENDER City or Township
Blake Farm BLVD 34.33485 -77.758933
Highway/Street Latitude(decim d degrees) Longitude(decim d degrees)
3. A pproxim ate date land-disturbing activity will corn m once:
4. P urpose of developm ent (residential, corn m ecial, industrial, institutional, etc.): Residential
5. T otal acreage disturbed or uncovered (including off-site borrow and waste areas): 17.0
6. A mount of fee enclosed: $1 ,700.00 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling am cunt (Exam ple: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ .
7. H as an erosion and sediment control plan been filed? Yes ❑ Enclosed E No 0
8. P erson to contact should erosion and sedim ent control issues arise during land-disturbing activity:
N ameDonald Aiken E-m al [e-mail]
Phone: 0 fice# M chile# 910-508-0017
9. L andowner(s)of Record (attach accom panied page to list additional owners):
Pender 1164 LLC 9 10-515-9561
Nam e P hone: 0 fice#o M bile#
1202 Eastwood Rd
Current M ailing Address C urrent Street Address
Wilm hgton NC 28403
C ity S tate Z ip C ity S tate Zip
10. D eed Book No. Page No. Provide a copy of the most current deed.

Part B.
1. Corn pany(ies)who are financially responsible for the land-disturbing activity(Provide a corn p'ehensive list
of all responsible parties on accompanied page.) If the corn pany is a sole proprietorship or if the landowner(s)is
an individual(s), the nam e(s)of the owner(s)m ay be listed as the financially responsible party(ies).
D.R. Horton, Inc. e [e-mail]
Com pany Name E -m al Address
6752 Parker Farm Drive, Suite 210
Current M cling Address C urrent Street Address
Wilm ngton NC 28405
City S tate Z ip C ity S tate Zip
Phone: 0 fice# 910-515-9561 M cbile#
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 subm L 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 corn pany registered on the NC Secretary of State
business registry, give nam e and street address of the Registered Agent:
Name of Registered Agent E -m al Address
Current M aling Address C urrent Street Address
City S tate Z ip C ity S tate Zip
Phone: O fice# M chile#
Name of Individual to Contact(if Registered Agent is a com any)
(b) If the Financially Responsible Party is not a resident of North Carolina, give nam e and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Elizabeth Shelton e [e-mail]
Name of Registered Agent E -m al Address
6752 Parker Farm Drive, Suite 210
Current M aling Address C urrent Street Address
Wilm ngton NC 28405
City S tate Z ip C ity S tate Zip
Phone: 0 fice # 910-515-9561 M chile#
Nam eof 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 the information pr vided herein.
-ZSA\ C4-'\( CV\ - ti\S,cWI
Type or p int name . Title or Authority
n
Signature Date
I, J(A..(01 v)r) . a Notary Public of the County of /JE1 ft1INIOVeZ
State of North Carolina, hereby certify that (-5t10-11114 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
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Witness my hand end notarial seal, this 2 day of , 20 23
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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:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record_
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#