NCC216459_FRO Submitted_20211118

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 Belhaven Water Street Project
2. Location of land -disturbing activity: County beauron City or Township ' UW'I U' DC"'a"C"
Highway/Street Water Street Latitude 35.537910 Longitude-76.623360
3. Approximate date land -disturbing activity will commence: 11/01/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.31 Acres
6. Amount of fee enclosed: $ 325.00 . 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 Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James Stephenson E-mail Address [e-mail]
Telephone Cell # 919-219-8238 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pantego Creek, LLC
Name Telephone Fax Number
416 Pollock Street
Current Mailing Address Current Street Address
New Bern, NC 28560
City State Zip City State Zip
10. Deed Book No. 1850 Page No. 87 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):
Beacon Street Development Cc r [e-mail]
Q_CName E-mail Address
3304 Six Forks Road 3304 Six Forks Road
Current Mailing Address
Raleigh, NC 27609
City State Zip
Telephone [phone]
Current Street Address
Raleigh, NC 27609
City State Zip
Fax Number 919-785-1446

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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
Telephone
State Zip City State Zip
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 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.
IfiME S iC'. V\)
Type or print name
Signa
WIMM"' �
State of North Carolina, hereby certify that
personally before me this day and being
executed by him.
'RrLaSi Oer4 T
Title or Authority
Date
a Notary Public of the County of AK
VLt 'l - Wi ky appeared
July sworn acknowledged f that the above form was
Witness my hand and notarial seal, this day off , 20 2
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