NCC216058_FRO Submitted_20211109

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 VII
2. Location of land -disturbing activity: County Onslow City or Township Swansboro
Highway/Street Cooke Dr. Latitude 34.7310 Longitude-77.1839
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):. 43.3
6. Amount of fee enclosed: $ 2,860.00 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 filed? 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
121 Garnet Lane _ 121 Garnet Lane
Current Mailing Address_ Current Street Address
Jacksonville NC 28546
City State Zip
10. Deed Book No. 3525 Page No.
Part B.
Jacksonville NC
City State
AR7
Fax Number
28546
Zip
Provide a copy of the most current deed.
1. Company (ies) 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 firm is a sole
proprietorship the name of the owner or manager may be listed as the financially 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 28546 . Jac_� Jacksonville NC 28546
City State Zip City State 2ip

[phone]
Telephone,__ 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 M-� 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. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Maifing 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
TypSX pri t na Title or Authority
"igna Date
a Notary'Public of the County of f��0%.L)
State of North Carolina, hereby certify that 0 1 10-4e\' rh-1D r+1D r\ appeared
personally before me this day and being duly swom acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of ___ Se—V `kur 20 91
Nota -
JE$S11�Q' AWREN;Gi
Nb��i Public
North Carolina My commission expires LL4-�V_ a
Onstow County