NCC232615_FRO Submitted_20230829

FINANCIAL RESPONSIBILITY/OWNERSH1P 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. Protect Name Lombardi house
2. Location of land-disturbing activity: County Onslow City or Township Holly Ridge
Highway/street713 Lake Catherine Dr.l ague Longitude
3. Approximate date land-disturbing activity will commence: 6/10/22
4. Purpose of development(residential,commercial,Industrial,institutional, etc.): Residential
5. Total acreage disturbed or uncovered(including oft site borrow and waste areas): .21 aC
6. Amount of fee enclosed: $ N/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 application fee is S5B5),
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
B. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ben West E-mail Address bwesJ@loganhomes,com
Telephone 910-5OR-onsn Celt# N/A Fax# N/A
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Joseph & Maryann Lombardi 910-452-7175 N/A
Name Telephone Fax Number
8 Maiden Lane
Current Mailing Address Current Street Address
Glenhead, NY 11545
City State Zip City State Zip
10. Deed Book No.5627 Page No. 420-422 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firms) 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 fine Is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Logan Homes nmeltonta'�.loganhomes.com
Name E-mail Address
60 Gregory Rd
Current Mailing Address Current Street Address
Belville, NC 28451
City State Zip City State 'Zip
Telephone [phone] Fax Number N Is*

91
Telephone [phone] Fax Number duIA,
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. lithe 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
Belville, NC 28451
City State Zip City State Zip
Telephone [phone] Fax NumberAril*
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
1/\ 11/141 3/4l=eat:
Signature Date
I, :lie C.n-eA ' h.11•,S , a Notary Public of the County of 311.1n.S.o v)E.
State of North Carolina, hereby certify that 1 L& fv.gQ appeared
personally before me this day and being duly sworn ack�tvtedged that the above form was executed
by him. g
Witness my hand and notarial seal, this 16 day of mb rclh 20 a-a-
Jeanette Phil '.Nok --� �--
;' NOTARY PUBLIC
a/Brunswick County,NC
My I mission Expires October 1 ,2023 My commission expires