HomeMy WebLinkAboutNCC216023_FRO Submitted_20211124FINANCIAL RESPONSIBILITYIOWNERSHIP 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. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Coastal Meadows
2. Location of land -disturbing activity: County Carteret City or Township Stella
Highway/Street Stella Rd Latitude 34.786037 Longitude-77.143105
3, Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29.41
6. Amount of fee enclosed: $ 1950.00 . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameJames Maides E-mail Address jamesmaides@csbenc.com
Telephone 910-938-5900 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Matthew, Gerald, and Jettie Pelletier
910--581 -8194
Name
Telephone Fax Number
312 Roosevelt Road, Unit C
312 Roosevelt Road, Unit C
Current Mailing Address
Current Street Address
Jacksonville, NC 28546
Jacksonville, NC 28546
City State Zip
City State Zip
10, Deed Book No. 1578 Page No. 209 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):
E & J Developers, LLC
jamesmaides@csbenc.com
Name
E-mail Address
166 Center St
166 Center St
Current Mailing Address
Current Street Address
Jacksonville, NC 28546
Jacksonville, NC 28546
City State zip
City State Zip
Telephone 910-938-5900
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.
Type or print name Title or Authority
!�r it 2
Date
i
I, r a Notary Public of the County of OnSl-bw
State of North Carolina, hereby certify that _' 4a'&yy -s . mooS appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness mg, RtlkMIM4,�notarial seal, this �r�day of 2j 20
T NOTARY'.
otary
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