NCC221006_FRO Submitted_20220310

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FINANCIAL RESPONSIBILITYZOWNERSHIP 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. Village Green Subdivision Phase 2
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Shallotte
Highway/Street Star Cross Drive Latitude 33.9233' Longitude-78.0063'
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 57
6. Amount of fee enclosed: $ 5,700.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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:
P.E. J. Phillip Norris, norris
Name E-mail Address p @ntengineers.com
Telephone [phone] Cell # 910-471-9638 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SH-VILLAGE GREEN, LLC 910-791-1196
Name Telephone Fax Number
P.O. Box 3167 2201 Burnett Blvd.
Current Mailing Address Current Street Address
Wilmington NC 28406 Wilmington NC 28401
City State Zip City State Zip
4666 13571136111365/136911373
10. Deed Book No. Page No. 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 sale proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
SH-VILLAGE GREEN, LLC [e-mail]
Name E-mail Address
P.O. Box 3167 2201 Burnett Blvd.
Current Mailing Address Current Street Address
Wilmington NC 28406 Wilmington NC 28401
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:
Current Mailing Address
City State
Telephone
Email 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
City State
Telephone
E-mail Address
Current Street Address
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.
Nathan Sanders Manager
Type or print name Title or Authority
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5i nature Date
lbA ?a Notary Public of the County of M p -) v�
State of North Carolina, hereby certify that
appeared personally before me this day and being duly sworn acknowledge that the above form was
executed by him.
Witness my hand and notarial seal, this ��_ day of 20 Qt_—
Seal Notary
u`&ee�aaeasfor
My commission expires a O
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