NCC221980_FRO Submitted_20220531

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM NT 20110
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. Old Ferry Road Subdivision
1. Project dame
2. Location of land -disturbing activity: County Brunswick City or Township Supply
Highway/Street 3047 Old Ferry Rd. Latitude 33.972 Longitude -78263
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0
6. Amount of fee enclosed: $ 300.00 . 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. -
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone]
Cell # 910-471-9638 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Janie F. Brown 910-443-2361
Name
Telephone Fax Number
853 Heron Landing Wynd
853 Heron Landing Wynd
Current Mailing Address
Current Street Address
Supply NC
28462 NC 28462
City State
_Supply
Zip City State Zip
10. Deed Book No. 4472
Page No. 931 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 orfifm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Janie F. Brown
[e-mail]
Name
E-mail Address
853 Heron Landing Wynd
853 Heron Landing Wynd
Current Mailing Address
Current Street Address
NC
Supply
28462 Supply NC 28462
City State
zip City State Zip
910-443-2361
NIA
Telephone
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 State Zip
Telephone
E-mail Address
Current Street Address
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 State Zip
Telephone
E-mail Address
Current Street Address
City Sta#e 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 attomey-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.
Janie F. Brown
T e or print n�e
ignature
State of North Carolina, hereby certify that
appeared personally before me this
executed by him.
Witness my hand and notarial
0t
Title or Authority
Date
a Notary Public of the County of�
a.Yet+ - ) '> l�,tn
day and being duly sworn acknowledged that the above form was