HomeMy WebLinkAboutNCC220638_FRO Submitted_20220204FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 NIA in the blank.)
Part A.
1. Project Name Ballentlne Grove
2. Location of land -disturbing activity: County Carteret City or Township Cape Carteret
Highway/Street Hwy 24 Latitude 34.727 Longitude-76.927
3. Approximate date land -disturbing activity will commence: 111 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.8
6. Amount of fee enclosed: $ 3,600.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed X
91
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Donald Aiken Email Address daiken@drhorton.com
Telephone NIA Cell # 910-508-0017 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Salt Creek Holdings, LLC
Name
505 Crestwood Dr.
Telephone
505 Crestwood Dr.
Fax Number
Current Mailing Address Current Street Address
Newport NC 28570 Newport NC 28570
City State Zip City State Zip
10. Deed Book No. N/A Page No. 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.
D.R. Horton, Inc. elshelton@drhorton.com
Name E-mail Address
131 Racine Dr., Suite 201 131 Racine Dr., Suite 201
Current Mailing Address Current Street Address
Wilmington NC 28403 Wilmington NC 28403
City State Zip City State Zip
Telephone 910-515-9561 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:
Elizabeth Shelton
elshelton@drhorton.com
Name of Registered Agent
E-mail Address
131 Racine Dr., Suite 201
131 Racine Dr., Suite 201
Current Mailing Address
Current Street Address
Wilmington NC 28403
Wilmington NC 28403
City State Zip
City State Zip
Telephone 910-515-9561
Fax Number
(c) In order to facilitate Express Permitting, it
is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
HB Next Corporation
dtruax@hbnext.com
Engineering Firm or other consultant
E-mail Address
David Truax
678-615-5003
Individual contact person (type or print)
Telephone 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.
Elizabeth Shelton
Vice President
y0e or nam ' Title or Au onty
ignature Date
I, _-. 1 A1J kL /JJV r.; 12`A' __ .a Notary Public of the County of l�� &AAt Ul .
State of North Carolina, hereby certify that EL j _LA';Sr ; 4 _ S 14F L ; O k) appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
04611111u11111 ;.
Witness r a�pz#, , ', nal seal, this i day of -C-Eer 20 Jso 1
Z `-' Notary
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