NCC216892_FRO Submitted_20211215

Pitt County
Planning Department
Development Services Building
a� 1717 W. 5th Street
Cpgo Greenville, 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 Tucker Hill Farm Subdivision, Sections 1 & 2
2. Location of land -disturbing activity: County Pitt
City or Township Grimesland Township , and Highway/Street NCSR 1759 - Tucker Road
3. Approximate date land -disturbing activity will be commenced: December 2021
4. Purpose of development (residential, commercial, industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 8.6
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 Kenneth Fisher Telephone [phone]
8. Landowner(s) of Record (Use blank page to list additional owners):
Tucker Hill Farms, LLC
Name(s) Name(s)
2625 Charles Boulevard
Current mailing address Street address
Greenville NC 27858
City State Zip City State Zip
9. Recorded in Deed Book No. 4087 Page No. 850
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):
Tucker Hill Farms, LLC
Name of person(s) or Firm(s) Name(s)
2625 Charles Boulevard
Current mailing address Street Address
Greenville NC 27858
City State Zip City State Zip
252-413-9090
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.
Kepneth Fisher
Ve or pi i a ti
Signature
Managing Member
Title Auth rity
i 2 2
Date
1, /V, 7-8A �'� LL&LLS , a Notary Public of the County of / State
of North Carolina, hereby certify that Kenneth Fisher
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 Z6 may of G 2021
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