NCC243016_FRO Submitted_20241001

N B#nt23068
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
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name The Oaks at Mill Creek
*If this project 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 Pender City or Township Topsail
Highway/Street Mill Ill Creek Rd. LatltUde(decimal degrees)34.464 L -77'556
ongltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 10/1/02
4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 19.64
6. Amount of fee enclosed: $2,000.00 . 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 0 Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Named. Phillip Norris, P.E. E-mail [e-mail]
Phone: Office# 910-287-5900 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Oaks at Mill Creek FO, LLC 803-917-6800 803-917-6800
Name Phone: Office# Mobile#
139B S. Boca Bay Lane 139B S. Boca Bay Lane
Current Mailing Address Current Street Address
Surf City, NC 28445 Surf City, NC 28445
City State Zip City State Zip
10. Deed Book No.4832 Page No.2014 Provide a copy of the most current deed.

Part 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).
The Oaks at Mill Creek FO, LLC [e-mail]
Company Name E-mail Address
139B S. Boca Bay Lane 139B S. Boca Bay Lane
Current Mailing Address Current Street Address
Surf City, NC 28445 Surf City, NC 28445
City State Zip City State Zip
Phone: Office# 803-917-6800 Mobile#[phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control 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:
Eric Shirley [e-mail]
Name of Registered Agent E-mail Address
139B S. Boca Bay Lane 139B S. Boca Bay Lane
Current Mailing Address Current Street Address
Surf City, NC 28445 Surf City, NC 28445
City State Zip City State Zip
Phone: Office# 803-917-6800 Mobile# [phone]
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)

the Financially Responsible Party is engaging in business under an assumed name,give name under
slicn the company is Doing. Business As. If the Financially Responsible Party is an individual, General
rtnership,.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 proviaec
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 should there be any change in the information provided herein.
Eric Shirley ICH
Type or print e j Title or Authority
Signature � Date
I. gnel (A) tu6t I , a Notary Public of the County o (\k(A) [bow
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State of North Carolina, hereby certify that Ex ( , V7)V )\ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal,this day of ( +- , 20
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