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HomeMy WebLinkAboutNCC231953_FRO Submitted_20230626 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.) Part A. 1. Project Name Oak Grove(a) Blake Farm 2. Location of land-disturbing activity: County Pender City or Township Topsail Township Highway/Street US HWY 17 Latitude 34° 19' 31"N Longitude 77°45' 54"W 3. Approximate date land-disturbing activity will commence: October, 2022 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11.0 6. Amount of fee enclosed: $ 715.00 . 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 Enclosed_X 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Madison Robideau E-mail Address madison(atrasklandco.com Telephone 910-799-8755 Cell# 910-599-0558 Fax# 910-799-8785 9. Landowner(s)of Record (attach accompanied page to list additional owners): Edisto Senior Real Estate, LLC 910-799-8755 910-799-8785 Name Telephone Fax Number 1022 Ashes Drive, Suite 201 Current Mailing Address Current Street Address Wilmington NC 28405 City State Zip City State Zip 10. Deed Book No. 4775 Page No. 1604-1605 Provide a copy of the most current deed. Part B. 1. 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): Trask Land Company, Inc. raiford(ctrasklandco.com Name E-mail Address 1022 Ashes Drive, Suite 201 Current Mailing Address Current Street Address Wilmington NC 28405 City State Zip City State Zip Telephone 910-799-8755 Fax Number 910-799-8785 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone 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. dolt- Raiford G. Trask, Ill .MaRacier--Trask Land Company, Inc. Type or pri e Title or Authority Signa ure Date I, \ -e+ iG w , a Notary Public of the County of t°42 rdinoi& State of North Carolina, hereby certify that 2t& (Di _ (: T Z& --(l i 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 ZA day of 0) , 20 MA171SCN RQgIDEAIJ Ne�TA�RY PUBLIC Notary nover County North Carolina My commission expires .130/12- My Commission Expires Aug.30,2022 Permission to Work on and Enter on Land I certify that I am authorized to grant and do in fact grant permission to Trask Land Company to do the work on the land zuestion as authorized by this permit, and to the Erosion Control Inspection and his .g-nt-'to e ter on the land in question in connection related to this permit. f Blake Farm North Commercial, LLC (7/X ))---' Signature P Entity Dat