NCC224163_FRO Submitted_20230110

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 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. Baxter Station
1. Project Name
2. Location of land -disturbing activity: CountyCurrltuck City or Township Moyock
Highway/Street Baxter Lane Latitude 36.3221 Longitude-76.1054
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): 55
6. Amount of fee enclosed: $ . 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 Justin Old [e-mail]
Telephone [phone] cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
North -South Devl Group LLC [phone]
Name
417 Caratoke Hwy, Unit D
Current Mailing Address
Moyock NC
City State
10. Deed Book No_ 1421
Telephone Fax Number
417 Caratoke Hwy, Unit D
Current Street Address
27958 Moyock NC 27958
Zip City State Zip
Page No. 801 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
North -South Devl Group LLC [e-mail]
Name E-mail Address
417 Caratoke Hwy, Unit D
Current Mailing Address
Moyock NC 27958
City
State Zip
417 Caratoke Hwy, Unit D
Current Street Address
Moyock NC 27958
City State 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
Telephone
E-mail Address
Current Street Address
State Zip 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:
Justin Old
Name of Registered Agent
417 Caratoke Hwy, Unit D
[e-mail]
E-mail Address
417 Caratoke Hwy, Unit D
Current Mailing Address Current Street Address
Moyock NC 27958 Moyock NC 27958
city
State Zip City
Telephone [phone] 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.
Justin Old
Type or print na
Signature
Registered Agent
Title or Authority
/a-7-aa
Date
I, We , a Notary Public of the County of (�"CL
State of No Carolina, hereby certify that L ld— appeared
personally before me this day and being d4 sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
PUBLIC
day of Q ' , 20 z
kl_�W
Not ry 7
My commission expires ` 262S