NCC240570_FRO Submitted_20240229

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 NCG01 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 Heritage at Marvin - Offsite Sewer Extension
*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 Union City or Township Marvin
New Town Road 34.98621 -80.82605
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1/1/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.65
6. Amount of fee enclosed: $300 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name SCOTT STEARNS E-mail Address [e-mail]
Phone: Office# 704-909-9246 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JAMES & MARY VACA
Name Phone: Office# Mobile#
1303 LARKRIDGE COURT 1303 LARKRIDGE COURT
Current Mailing Address Current Street Address
WAXHAW NC 28173 WAXHAW NC 28173
City State Zip City State Zip
10. Deed Book No.6835 Page No. 164 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 OW/er{s)maybe listed as the financially responsible party(ies).
JCH OP, LLC [e-mail]
Company Name E-mail Address
283 Cranes Roost Blvd. Suite 250 283 Cranes Roost Blvd. Suite 250
Current Mailing Address Current Street Address
Altamonte Springs FL 32701 Altamonte Springs FL 32701
City State Zip City State Zip
Phone: Office#407-766-2400 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:
JCH OP, LLC [e-mail]
Name of Registered Agent E-mail Address
283 Cranes Roost Blvd. Suite 250 283 Cranes Roost Blvd. Suite 250
Current Mailing Address Current Street Address
Altamonte Springs FL 32701 Altamonte Springs FL 32701
City State Zip City State Zip
Phone: Office# 407-766-2400 Mobile# [phone]
Scott Stearns
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:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Ste 550 2626 Glenwood Ave, Ste 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City State Zip
Phone: Office# 800-924-9800 Mobile# -
Customer Service
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.
M. Scott S earns Asst. Secretary for JCH OP, LLC
Type or print na A Title or Authority
11 2C+10225
Signature Date
I, q..)v\t.. I Y l . trc,Vcb , a Notary Public of the County of lint k,.
State of rohna, hereby certify that CI I . . (�; C 4(-1`J 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 .M day of t( '.k.rn X( , 20 25
jkUL(A.111 ‘6A 1—T—WQ.1-,
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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:
MEADOWLARK HOMEOWNERS ASSOCIATION
(RANDY BAKER-PRESIDENT)
Name Phone: Office# Mobile#
1313 LARK RIDGE COURT
Current Mailing Address Current Street Address
WAXHAW NC 28173
City State Zip City State Zip
Deed Book No.340 Page No.226 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#