NCC216768_FRO Submitted_20211230

N&T #20163
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 NIA in the blank).
Part A.
1. Project Name Saucepan Bay Estates
2. Location of land -disturbing activity: County Brunswick City or Township Shallotte
Brick Landing Rd
Highway/Street (NC 179) Latitude 330 55' 9.88"
3. Approximate date land -disturbing activity will commence: January 2022
Longitude-781 24'21.5"
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
6. Amount of fee enclosed: $ 3,965.00
Residential
60.97 ac
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 Joseph K. Bland, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 910-512-8148 Fax # [phone]
i7
Landowner(s) of Record (attach accompanied page to list additional owners):
Saucepan Creek, LLC 910-486-4864
Name Telephone
2919 Breezewood Ave., Suite 100
Current Mailing Address Current Street Address
Fayetteville NC 28303
City State Zip City
10. Deed Book No. 4642
Part B.
Page No. 0867
Fax Number
State
Zip
Provide a copy of the most current deed.
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):
Saucepan Creek, LLC
Name
2919 Breezewood Ave. Suite 100
Current Mailing Address
Fayetteville NC 28303-5283
City State zip
Telephone [phone]
[e-mail]
E-mail Address
2919 Breezewood Ave. Sutie 100
Current Street Address
Fayetteville NC 28303-5283
City State Zip
Fax Number 910-485-0463

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 State
Fax Number
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:
of Registered Agent
Current Mailing Address
City
Telephone
State
Zip
E-mail Address
Current Street Address
City State
Fax Number
Zip
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.
Bryant Spencer Director of Land Development for RHH Land Investors, LLC
Type or rint name Title or Authority
'S-ao- a�
gnature Date
a Notary Public of the County of
State of North Carolina, hereby certify that L7f
appeared personally before me this day and
executed by him.
Witness my hand and notarial seal, this
TAMMY KsaN j
NOTARY PUBLIC
Brunswick County
North Carolina
My Commission Expires May 20, 2023
--------------
ng duly'sworn acknowledged that the above form was
My commission expires S -- ail - a0 la'3