NCC216239_FRO Submitted_20211109

N&T #21107
FINANCIAL RESPONSIBILITYIOWNERSHI!P 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 Environment and Natural Resources. (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 In The Pines RV & Cabin Village
2. Location of land -disturbing activity: County Brunswick
Highway/Street
NC 87
Latitude 34' 04' 49"
3. Approximate date land -disturbing activity will commence:
City or Township Bolivia
Longitude -78' 05' 49"
October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 845.00
12.46
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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 910-471-9638 Fax ## [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Judge Legacy, Inc. 843-826-1330
Name Telephone Fax Number
129 South Palm Drive
Current Mailing Address
Winnabow NC
City
State
10. Deed Book No. 4511
Part B.
Current Street Address
28479
Zip City
Page No. 0179
State
Zip
Provide a copy of the most current deed.
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):
Judge Legacy, Inc
Name
129 South Palm Drive
Current Mailing Address
VUnnabow NC 28479
City State Zip
[e-mail]
E-mail Address
Current Street Address
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 State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
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
State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
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.
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Type or pilint name Title or Authority
fu 21
• nature Date
I, pe nmn 477 \k A pn a Notary Public of the County of
State of North Carolina, hereby certify that Nr•j 4 n S a e
appeared personally before me this day and b ing duly swor acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this Q day of :Sune." , 20 -9,1
TAMMY T WftN
NOTARY PUBLIC
Brunswick County
North Carolina
My Commission Expires May 20, 2023
Notary
My commission expires 5 - a o — dU a :3