NCC232608_FRO Submitted_20230829

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 N/A in the blank.)
Part A.
1. Project Nam Logan Homes house
2 Location of land-disturbing activity: County Onslow City or Township Holly Ridge
Highway/Street 559 Moss Lake Lane Latitude Longitude
3. Approximate date land-disturbing activity wit commence: 6/3/2022
4. Purpose of development(residential,commercial,Industrial,institutional,etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): . AA at. ..
6 Amount of fee enclosed, 3N/A Waived by DEQ. The application fee of$65.00 per acre(rounded
up to the next acre)is assessed without a ceiling amount (Example:a 9-acre app'cation fee is$585)
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity;
Narne "t3fivt Jes 4- E ma'i Address_%owe a 10604, 1e S•e a el,Telephone Q i o• SO a•o�3�-o Cel # /�t A Fax# ly t
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Logan Developers, Inc. 910-452-7175
Nam Telephone Fax Number
60 Gregory Rd
Current Mailing Address Current Street Address
Belville, NC 28451
City State Zip City State Zip
10. Deed Book No. S t.ot Page No b 9 -Sf 9 ty Provide a copy of the most current deed.
Part B.
1_ Company (les) 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 s sole
proprietorship the name of the owner or manager may be listed as the financially responsible party
_Logan Developers, Inc. nmelton©Ioganhomes.com
Name E-mail Address
60 Gregory Rd
Current Mailing Address Current Street Address
Belville, NC 28451
City ip ity 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 E-mail Address
Current Mailing Address Current Street Address
City Stale 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:
D Logan [e-mail]
Name of Registered Agent E-mail Address
60 Gregory Rd
Current Mailing Address Current Street Address
Beiville, NC 28451
City State Zip City State Zip
Telephone [phone] Fax Number N l et
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.
Nancy Melton Preconstruction Coordinator
Type or print name Title or Authority
%-)Acv.. 31,`b.2►a.
Signature Date
I, -J. IRA\ 475 , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn ackn ledged that the above form was executed
by him.
Witness my hand and notarial seal, this_ I(4 day of 1 `ltrrj- , 20
Jeanette Phi! .9 }AO
'-r' NOTARY Mg C
Nola
• : ,l Brunswick County,NC
,.*COrntlisecn Expires October 17,2023 My commission expires (r �V' L 2. 3