NCC221765_FRO Submitted_20220512

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 Environmental Quality. Submit the completed forrn 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 Wylie Branch
2. Location of land -disturbing activity: County Pender Clty or Townshlp__ Hampstead
Highway/street _Island Creek Rd Latitude 34.3829 Longhude_-77.7913
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (Including off -site borrow and waste areas): 46.3
6. Amount of fee enclosed: $ 4,700.00 . 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 X Enclosed_ X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Anthony W. Sydes E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
A. Sydes Construction, Inc. [phone]
Name Telephone Fax Number
P.O. Box 7122 100 Carolina Plantation Blvd.
Current Mailing Address Current Street Address
Jacksonville NC
city State
10. Deed Book No. 4661
Part B.
28540 Jacksonville NC 28540
Zip City State Zip
Page No. 47 Provide a copy of the most current deed.
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.
Island Creek___ Developers, LLC [e-mail]
Name E-mail Address
P.O. Box 7122
Current Mailing Address
Jacksonville NC 28540
City -- - State Zip
100 Carolina Plantations Blvd.
Current Street Address
Jacksonville NC
City
State
28540
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
E-mail Address
Current Street Address
City State Zip City State _ Zip
Telephone
Fax Number
(b) 9 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 Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State . __ 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.
Anthony Sydes President
T — r print n e Title or Au or+ty
gnature Date
1, �v! ---- , a Notary Public of the County of
State of North Carolina, hereby certify that�h W appeared
personally before me this day and being duly swam acl(nowledged at the above form was
executed by him.
Witness my hand and notarial seal, this day of20
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