NCC223510_FRO Submitted_20221011

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 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 N/A in the blank.)
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Project Name: Allston Park Subdivision
2. Location of land -disturbing activity: County: Brunswick City or Township: Calabash
Highway/Street: —400 Shingletree Road NW Latitude: 33.93 N Longitude: 78.59 W
3. Approximate date land -disturbing activity will commence: As soon as permitted
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 56 ac (0.90 ac New)
6. Amount of fee enclosed: $65.00. 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: James Stariha E-mail Address
Telephone: (865) 380 — 3000 Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Clayton Properties Group, Inc.
Name
PO Box 4098
Current Mailing Address
Maryville, TN 37802
City State Zip
10. Deed Book No: 4601 Page No: 1342
(865) 380 — 3000
Telephone Fax Number
5000 Clayton Road
Current Street Address
Maryville, TN 37804-5550
City State Zip
Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Clavton Properties Group. Inc.
Name
PO Box 4098
Current Mailing Address
Maryville, TN 37802
City State Zip
Telephone:
(865) 380 — 3000
Telephone Fax Number
5000 Clayton Road
Current Street Address
Maryville, TN 37804-5550
City State Zip
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:
_CT Corporation System
Name
160 Mine Lake CourtSuite 200
Current Mailing Address
Raleigh, NC 27616
City State Zip
Telephone:
E-mail Address
160 Mine Lake CourtSuite 200
Current Street Address
Raleigh, NC 27616
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
State Zip
E-mail Address
Current Street Address
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.
SCC;-
Ty e or pri e Title or Authority
2- e'12-
Si6natur4 Date
a Notary Public of the County of (1Cd HO-04 €,•
State of North Carolina, hereby certify that , V—vSo\o\45(— appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this IQ day of t, - - 20 -2 !
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Notary
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NOTARY PUBLIC My commission expires
New Hanover County
North Carolina
My Commission Expires 10/06/2.024