NCC220546_FRO Submitted_20220201

Pitt County
Planning Department
ZX Development Services Building
�o 1717 W. 5th Street
C Greenville, North Carolina 27834-1696
Telephone: [phone] James F. Rhodes, AICP
Fax: [phone] Director
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 Coun Club Creek - Phase 2
2.
Location of land -disturbing activity: County,
Pitt
City or Township Ayden , and Highway/Street NCSR 1723 - Ryden Golf Club Rd.
3. Approximate date land -disturbing activity will be commenced: Fall, 2021
4. Purpose of development (residential, commercial, industrial, etc.):
Single Family Residential
5. Approximate acreage of land to be disturbed or uncovered: 12.6 Acres +/-
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 Dwight Verne]son Telephone [phone]
8. Landowner(s) of Record (Use blank page to list additional owners):
Garris-Evans Lumber Grp pany
Name(s) Name(s)
P.O. Box 3353
Current mailing address Street address
Greenville NC 27836
City State Zip City State Zip
9. Recorded in Deed Book No. 3642 Page No. 674
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):
Vicus Development, LLC - Attn: John Evans
Name of person(s) or Firm(s) Name(s)
P.O. Box 3353
Current mailing address Street Address
Greenville NC 27836
City State Zip City State Zip
[phone]
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.
John Evans Manager
Type o rint ame Title RRor��..utho ty
�Pz.
mature Date
I, El AN a" , a Notary Public of the County of p4 State
of North Carolina, hereby cert' y that '-B 6 ja 9V 8'P . S
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him.
Witness my hand and notarial s his2Q�iay of � 20A.
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My commission expires
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