NCC217144_FRO Submitted_20220105

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. The Reserve At Sunset Harbor - Phase 1
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Bolivia
Highway/Street Zion Hill Road Latitude 33.967 Longitude-78.220
3. Approximate date land -disturbing activity will commence: Summer/Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.6 AC
170)
6. Amount of fee enclosed: $ Fee already paid ($1,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 Johnny Harris E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The Reserve at Sunset Harbor, LLC. 910-638-5480
Name Telephone Fax Number
PO Box 349
Current Mailing Address Current Street Address
West End - NC - 27376-0349
City State Zip City State Zip
10. Deed Book No. 2615 Page No. 376 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 companyorfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
The Reserve at Sunset Harbor, LLC. [e-mail]
Name E-mail Address
PO Box 349
Current Mailing Address Current Street Address
West End - NC - 27376-0349
City State
Zip
City
State
Zip
Telephone [phone] 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 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
Current Mailing Address
City
Teleph
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 harPin
Johnny Harris
fypp or prjpt name
Member
Title or Authority
Date
S- IZ-Wd
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personally before me this day and being duly sworn nowledged that the above foamsarewas
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