NCC221262_FRO Submitted_20220422

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 N/A in the blank.)
Part A. 1. Project Name Pearl - Thomasboro Road Project
2.
43
Location of land -disturbing activity: County Brunswick City or Township Calabash
Highway/Street Thomasboro Rd Latitude Longitude
Approximate date land -disturbing activity will commence: Fall Of 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): land clearing only
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.25 ( 11 )
6. Amount of fee enclosed: $ 715.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Odell D. Williamson, Jr. E-mail Address [e-mail]
Telephone [phone] cell # 910-408-9090 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Pearl Development Company, LLC
910-251-8543 910-795-0031
Name
Telephone Fax Number
2618 New Village Way
Same
Current Mailing Address
Current Street Address
Wilmington NC 28405
Same
City State Zip
City State Zip
10. Deed Book No. ���03(� Page No.
1006 � IOCXP 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 sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
The Pearl Development Company, LLC
[e-mail]
Name
E-mail Address
2618 New Village Way
Same
Current Mailing Address
Current Street Address
Wilmington NC 28405
Same
City State Zip
City State Zip
Telephone [phone]
Fax Number 910-795-0031

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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(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
Telephone_
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
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.
Dr. DeCarol Williamson
Type or Kint n e
Signature
Member Manager
Title or Authority
og 1 c�a I a.oj i
Date
I. Annc�- 1� yey bay- L , a Notary Public of the County of iie,,) l-�XVIO �
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
Dr. DeCarol Williamson aooeared
duly sworn acknowledged that the above form was
Witness my hand and notarial seal, this _ vC day of September 20 21
Seal` NoTA;? ��� Notary
My commission expires�� J-U �La
PUBUG ,=c.
PVER C&.�e``111,