NCC220269_FRO Submitted_20220126

0
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 Patriot Pointe at Towne Pointe
2.
3.
4.
Location of land -disturbing activity: County Onslow City or Township Jacksonville
Highway/Street Rocky Run Road (SR 1413) Latitude 34°44'26" Longitude -77018' 4"
Approximate date land -disturbing activity will commence: January 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 55.7
6. Amount of fee enclosed: $ 3,640.00 . 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 Michael G. Tuton E-mail Address [e-mail]
Telephone [phone] Cell # NIA Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Onslow 22, LLC 910 577-1441
Name
P.O. Box 1066
N/A
Telephone Fax Number
1000 Hunters Trail
Current Mailing Address
Current Street Address
Jacksonville NC
28541 Midway Park NC 28544
City State
Zip City State Zip
10. Deed Book No. 3464
Page No. 175 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.
Onslow 22, LLC
[e-mail]
Name
E-mail Address
P.O. Box 1066
1000 Hunters Trail
Current Mailing Address
Current Street Address
Jacksonville NC
28541 Midway Park NC 28544
City State
Zip City State Zip

Telephone [phone]
Fax Number N/A
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
State Zip
E-mail Address
Current Street Address
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.
Michael G. Tuton Manager
Type or print name
Am -
Signature
Title or Authority
Date
a Notary Public of the County of Onslow
State of North Carolina, hereby certify that Michael G. Tuton appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. p \00111 1 I / /,,"/
Witne grid �tS�jr�'o�arial seal, this 03 day of November 2021
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