NCC222955_FRO Submitted_20220818

N0 a, f 11 v ARO:!,4 a
Financial Responsibility -Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson Sedimentation and Erosion Control Ordinanc
before completing and filing this form with the City of Wilson Erosion Control Division. (*Indicate N/A if a question is not applicable)
Field Name
Description
Comments
PROJECT Tracking
number
Complete
Application/NOI
Application Received date
SIC Code (Primary)
1522
Commercial (30001) = 1542, Highway (30005) = 1611, Industrial (30002
= 1541, Residential, Single Family Houses (SFE) = 1521, Residential,
1 other than SFE (30000) = 1522, others = blank
Project or Site name
Jetstream Phase III
Site Street Address
Huntsmoor Lane
Site City
Wilson
Site County
Wilson
Site State
NC
Site Zip Code
27896
Site/Facility Type of
Ownership
POF
Non -Government = POF (default)
Government -County = CNG
Government - Federal = FDF
Government - Municipal = MWD
Organization Government - State = STF
Approximate Activity
Start Date
June 30, 2022
Total Acres of
Disturbance
20.8 ACRES
FRO - First Name
David
**MUST be Financially Responsible Owner Person**
FRO -Last Name
Chapman
**MUST be Financially Responsible Owner Person**
FRO - Organization
Formal Name
Southbury Development, LLC
**MUST belong to Financially Responsible Owner**
FRO - eMail Address
[e-mail]
**MUST belong to Financially Responsible Owner**
FRO - Mailing Street
Address
20 Cochran Castle Circle
**MUST belong to Financially Responsible Owner**
j
FRO - Mailing
Supplemental Location
Text
**MUST belong to Financially Responsible Owner**
FRO - Mailing City
Pinehurst
**MUST belong to Financially Responsible Owner**
FRO - Mailing State
NC
**MUST belong to Financially Responsible Owner**
FRO - Mailing Zip Code
28374
**MUST belong to Financially Responsible Owner**
Latitude: Decimal
Degrees
35.765
Longitude: Decimal
Degrees
-77.956

(#) ACRES TO BE DISTURBED 20.8 AC X $150.00 /ACRE= $3120.00
Person(s) or Firm(s) financially responsible for this land disturbing activity: (If out of state, a registered agent in North Carolina
must be used.)
In case of a violation please list the preferred contact (either the Financially Responsible Person or Registered Agent on the line
below:
David Chapman
Financially Responsible Person
Richard Herring
Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by me while under oath. (This
form must be signed by the Financially Responsible Person if an individual or by an officer, director, partner, and attorney -in -fact,
or other person with authority to execute instruments for the financially responsible person if not an individual.)
10-07-21
Date
Developer
Title or tl�pr
Signature
David Chapman
Type or Print Name,// /� y
Developer `
Title Date
Notary Public of the County of 4�%� State of North Carolina
hereby certifies
t
personally appeared before me this day and under oath acknowledged that the
above form was executed by him.
Wltnesg,ruy hand and notary se d, this t' lS� day of ig�
(Notary Public)
H
My commission expires ��� �$.►�,;,tt�issip��'+•�1EL�:=
XOTA,9� o_ 9
' !�
couvo