NCC216488_FRO Submitted_20211201

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 Wooten Project
2. Location of land -disturbing activity: County Brunswick City or Township Supply
Highway/Street Stone Chimney Rd SW Latitude 34.00967778 N Longitude 78.27527778 W
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 65 . 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 Kelly Wooten
E-mail Address [e-mail]
Telephone_
Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
All L's LLC
[phone] [phone]
Name
Telephone Fax Number
199 Quilt Road SW
199 Quilt Road SW
Current Mailing Address
Current Street Address
Supply NC
28462 Supply NC 28462
City State
Zip City State Zip
10. Deed Book No. 4057
Page No. 1 191 Provide a copy of the most current deed.
Part B.
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.
All L's LLC
[e-mail]
Name
E-mail Address
199 quilt RD SW
Current Mailing Address
Current Street Address
Supply NC
28462
City State
Zip City State Zip

Telephone[phone] Fax Number9107547866
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
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.
Kelly Wooten Managing Member
Type or print name
Title or Authority
Signature Date
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, a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of , 20
Seal
Notary
My commission expires