NCC215163_FRO Submitted_20210914

cap, Pitt County
Planning Department
Development Services Building
xa 1717 W. 5th Street
CGreenville, North Carolina 27834-1696 James F. Rhodes AICP
Telephone: [phone] Director
Fax: [phone]
Financial Responsibility / Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land -disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Duck Thru No. 59
2. Location of land -disturbing activity: County Pitt
City or Township Arthur Township , and Highway/Street NCSR 1206-Bell Arthur Rd
3. Approximate date land -disturbing activity will be commenced: September 2021
4. Purpose of development (residential, commercial, industrial, etc.): Commercial
5. Approximate acreage of land to be disturbed or uncowred: 5.0
6. Has an erosion and sedimentation control plan been filed? Yes X No
7. Person to contact should sedimentation control issues arise during land-disturbing_activity:
Name J. Michael Harrell Telephone [phone]
8. Landowner(s) of Record (Use blank page to list additional owners):
Phillip A. Lewis
Name(s)
Name(s)
P. O. Box 662
Current mailing address
Street address
Greenville NC 27834
City State Zip
City State Zip
9. Recorded in Deed Book No. 3779
Page No. 385
Part B.
1. Person(s) or firm(s) who are financially
responsible for this land -disturbing activity (Use
the blank page to list additional persons
or firms):
Jernigan Oil Company, Inc.
Jernigan oil Company, Inc.
Name of person(s) or Firm(s)
Name(s)
P. O. Box 688
415 Main Street
Current mailing address
Street Address
Ahoskie NC 27910
Ahoskie NC 27910
City State Zip
City State Zip
252-332-2131
252-332-2131
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner (Use blank page to list additional partners):
Name(s) Name(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone Telephone
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/her attorney -in -fact or if not an individual by an officer, director, partner, or
registered agent with 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.
J. Michael Harrell
President
Type or print name Title or Authority
,., Vo 5/ I9t / z i
6igignature Date
Ac-*'�� , a Notary Public of the County of State
v
of North Carolina, hereby certify that J. Michael Harrell
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 I q""day of MI atj .2021 .
My commis`1*
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