NCC242424_FRO Submitted_20240812

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of intent to Fund
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, including any
act vity under a common plan of development of this size as covered by the NCGO1 permit, before this form
an' an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Qu=lity Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Re!ional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
nu ber is unavailable, place N/A in the blank.)
Pa A.
1. Project Name Fynloeh Chase North Subdivision
`If this proj ct involves American Rescue Plan Act(ARPA) funds; list the Project Name or Project
Number(e g., SRP-D ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Wayne City or Township Nahunta
Highway/Street Gov. Aycock Rd. Latitude(decimal degrees) g t LOn nude decimal degrees)
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):
19.5
6. Amount of fee enclosed: $2000 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
1
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Stacy Johnson E-mail Address [e-mail]
Phone: Office# 1919-921 -2642 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J & N Developers, LLC 919-921 -2642
Name Phone: Office# Mobile#
Post Office Box 658 501 South Pearl St
Current Mailing Address Current Street Address
Princeton, NC 27569 Princeton, NC 27569
City I State Zip City State Zip
10. Deed Book No. 3591 Page No. 804 Provide a copy of the most current deed.

Pa t B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
J & N Developers, LLC [e-mail]
Company Name E-mail Address
Post Office Box 658 501 South Pearl St
Current Mailing Address Current Street Address
Princeton, NC 27569 Princeton, NC 27569
City State Zip City State Zip
Phone: Office# 919-617-8067 Mobile#[phone]
Nite: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
thr landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
co trol plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual. General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name •
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(s)
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 Party). I agree to provide
corrected information_T should there be any change in the] informationo provided herein.
I-A C k 1 o k r opt l/ efig-ZG� Grt a.. C GA/-
Type or prin name Title or Auth rity V
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81 6/02002 ti
Signature Date
1 1 , } _ n 1
I, tSi)��\�� �� , a Notary Public of the County of \(�V\t \
State of North Carolina, hereby certify that C, ,O A .SOn appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Wtness my hand and notarial seal, this , (Q day of Sk- , 20 24-
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