NCC222239_FRO Submitted_20220622

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 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 The Bluffs on Broad Creek
2.
3.
Location of land -disturbing activity: County Carteret City or Township Cedar Point
Highway/Street Pearson Circle Latitude 34.676844° Longitude -77.1018330
Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.5
6. Amount of fee enclosed: $ 1 ,000.00 . 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Elijah T. Morton E-mail Address [e-mail]
Telephone [phone] cell # 910-389-6610 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Norrine H. Gray 850-982-7900
Name Telephone Fax Number
9590 Pinecone Drive
Current Mailing Address Current Street Address
Cantonment FL 32533
City State Zip City State Zip
10. Deed Book No. 370, 762, 603, 741 page No. 403, 469, 100, 332 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):
South State Development, LLC [e-mail]
Name E-mail Address
121 Garnet Lane
Current Mailing Address Current Street Address
Jacksonville NC 28546
City State Zip City State Zip
Telephone 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
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
(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
Current Mailing Address
E-mail 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.
Jennie Ward Member
Typ Sri ame Title or Authority
Signatu Date
1,��'5iCa_ LOLU) E, a Notary Public of the County of OtteApt3
State of North Carolina, hereby certify that , le_nrtk wo_r� 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 day of f t 20 a �-
tOE
J.1ES�iCA LAWREN
Notary PUORC Notar
Sadith Carotins
Onstow Covryty, My commission expires JU Nt r2D. mil"