NCC221773_FRO Submitted_20220509

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Sandy Bay
2. Location of land -disturbing activity: County Pamlico City or Township Arapahoe
Highway/Street Janiero Rd Latitude 34.9899N Longitude 76.7620 W
3. Approximate date land -disturbing activity will commence: April 20, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5 ac
6. Amount of fee enclosed: $ 325.00 . 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 tee
is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
A
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Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Darrell Wiard E-mail Address darrell.newaterfrontCd_)amail.com
Telephone [phone] Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Ocean Minnow LLC
Name
181 Weatherby Drive
Current Mailing Address
Merritt NC 28556
City State Zip
252-229-7707
Telephone Fax Number
Current Street Address
City
10. Deed Book No. 665 Page No. 794-799 Provide a copy
Part B.
1. Person(s) or firm(s) who are financially responsible for the land
comprehensive list of all responsible parties on an attached sheet):
Ocean Minnow, LLC
Name E-mail Address
181 Weatherby Drive _
Current Mailing Address
Merritt NC 28556
City State Zip
Current Street Address
City
State
MAR 2 9 2OZZ
activity (Provide a
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
E-mail Address
urrent Street Address
State Zip City
Telephone Fax Number
State 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
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone 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.
Darrell Wiard _Manager _
Type or pint name Title or Authority
s, �_All 4 — -J — V — 7,?,—
Signature Date
I, j (I II I'nln, N.,.,,,,fll l',) , a Notary Public of the County of Faali'm
State of North Carolina, hereby certify that wy-a-1 1 W lay _, appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my haRq,W)d notarial seal, this N day of rW�Gtrwt , 20 22
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