NCC222923_FRO Submitted_20220816

FINANCIAL 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. Submit the completed form to the
appropriate Regional Office. (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 NameANTIOCH FARM SUBDIVISION
2. Location of land -disturbing activity: County COLUMBUS City orTownship WHITEVILLE
Highway/Street ANTIOCH CHURCH RD Latitude 34.2291 Longitude -78.722
3. Approximate date land -disturbing activity will commence: J U N E 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27 AC + 4- Ac - z 3 Ac,
6. Amount of fee enclosed: $ 1,755.00 + 4 no.op = $20 15'. a 0
. 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:
Name LARRY ANDERSON E-mail Address andersonengineeringpa(LDgmail.com
Telephone [phone] -Cell 4 910-608-2808 Fax [phone]
9. Landownjer of e Sri (attaptLaccornpanied page to list additional owners):
)f
339-832-3208
Name
Telephone Fax Number
8620 RIVER ROAD
8620 RIVER ROAD
Current Mailing Address
Current Street Address
WILMINGTON, NC 28412
WILMINGTON, NC 28412
City State zip
City State Zip
10. Deed Book No­j;;?!S' Page No.--7�S®' _Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
THRIVING, LLC
[e-mail]
Name
E-mail Address
8620 RIVER ROAD
8620 RIVER ROAD
Current Mailing Address
Current Street Address
WILMINGTON, NC 28412
WILMINGTON, NC 28412
City State Zip
city State Zip
Telephone [phone]
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
Current Mailing Address
city
Telephone
E-mail Address
Current Street Address
State 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
City
Telephone,
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
Michelle Carlisle
Signature
Manager
Title or Authority
/L:---) r
Date
a Notary Public of the County of ,✓'a,, p` _
State of North Carolina, hereby certify that appeared
personally before me this day and being duly swom acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 120, 21
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GODC`q'''O``�.
Seal
Notary
My commission expires�-