NCC215547_FRO Submitted_20211007

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 Name Peytons Ridge, Section 9
2, Location of land -disturbing activity: County 2nSIOW City or Townshlp Swansboro
Highway/street Misty Pond Dr. Latitude 34.7290 Longitude -77.1987
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): 20.1
6. Amount of fee enclosed: $ 1,365.00 . 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 tiled? Yes _ No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name_ Elijah Morton E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
South State Development, .LLC [phone]
Name Telephone Fax Number
121 Grant Lane 121 Grant Lane
Current Mailing Address Current Street Address
Jacksonville NC 28540 Jacksonville NC 28540
City State Zip City Stater Zip
10. Deed Book No. 5208 Page No. 365 Provide a copy of the most current deed.
Part B.
Company (!as) 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 i7rm is a sole
proprietorship the name of the owner or manager may be listed as the t7nanclally responsible party.
South State Development, LLC
Name
121 Garnet Lane
Current Mailing Address
[e-mail]
E-mail Address
121 Garnet Lane
Current Street Address
Jacksonville NC 28540 Jacksonville NC MAO
City State Zip City 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
Current Mailing Address
City - - State Zip
Telephone
E-mail Address _
Current Street Address
City
Fax Number
State Zip
(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 T 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 attomey-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.
Elijah Morton President
Ty r p 'nt name Title or Authority
912-
na Date
-e_55 t CCiI.(. r YlC e , a Notary Public of the County of _ s Dili
State of North Carolina, hereby certify that t �I]Gr�"G�ir -` appeared
personally before me this day and being duly swGP4 acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day off
JESSICA A11��VVREit�Cf Notary -
Notat irblic My commission expires '►'� � iF
North Carotil"
Onstow Count