NCC215874_FRO Submitted_20211027

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 Environment and Natural Resources. (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 Justice Ridge
2. Location of land -disturbing activity: County Onslow City or Township Jacksonville
Highway/Street NCSR 1217 Latitude 340 44' 54" Longitude 771 30'07"
3. Approximate date land -disturbing activity will commence: July 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 24.9
6. Amount of fee enclosed: $ 1,625 . 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 filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Pierce E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
James Justice Heris [phone]
Name Telephone Fax Number
3701 Columbine Circle 3701 Columbine Cir
Current Mailing Address Current Street Address
Charlotte NC 28211 Charlotte NC 28211
City State Zip City State Zip
10. Deed Book No. 1534 Page No. 465 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Beaver Creek Investors, Inc. [e-mail]
Name E-mail Address
P.O. Box 1685 409 Johnson Blvd
Current Mailing Address
Jacksonville NC
City State
Telephone [phone]
28541
Zip
Current Street Address
Jacksonville NC 28540
City State
Fax Number 910-346-1210
Zip

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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Betty Bullock
Name of Registered Agent
P.O. Box 1685
Current Mailing Address
Jacksonville NC 28541
[e-mail]
E-mail Address
405 Johnson Blvd.
Current Street Address
Jacksonville NC 28540
City State Zip City State Zip
Telephone [phone] Fax Number [phone]
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.
Betty Bullock
President
Title or Authority
Date
1, kAC1`CR'nQa QXG )Q= CA. , a Notary Public of the County of O WOt A
State of North Carolina, hereby certify that? )Ptt.�Sk 161 w)-c-Ac appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 11 `t day ofy , 20a\
GD
N a
Seal
My commission expires elm V1, aM5
MCDONALDNOTARY PUBLIC
Onslow County
North Carolina
FHANNA
..,��cinn Exoires August 17.2025 —