NCC220530_FRO Submitted_20220216

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 N/A in the blank.)
Part A.
1. Project Name: BlueWater Development
2. Location of land -disturbing activity: County: Brunswick City or Township: N/A
Highway/Street US Hwy 17_ Latitude: 33' 59' 22" N Longitude: 78' 21' 04"W
3. Approximate date land -disturbing activity will commence: January 7
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Mixed Use
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 33.2
6. Amount of fee enclosed: $ 3,400 The application fee of $100.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No: Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mary Catherine Santos E-mail Address: [e-mail]
Telephone: [phone] Fax #: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Shallotte 17 Ventures, LLC
Name
60 Gregory Rd, Suite 1
Current Mailing Address
Leland
City
NC
[phone]
Telephone
Same as Mailing Address
Current Street Address
28451
State Zip City
10. Deed Book No. 4701 Page No. 1282
Part B.
State
Fax Number
Provide a copy of the most current deed.
Zip
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):
Shallotte 17 Ventures, LLC [phone]
Name Telephone Fax Number
60 Gregory Rd, Suite 1 Same as Mailing Address
Current Mailing Address Current Street Address
Leland NC 28451
City State Zip City State Zip

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
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State 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:
Name of Manager
Current Mailing Address
City State
Telephone:
E-mail Address
Current Street Address
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.
D Loplan Manager
Type or print name Title or Authority
12131af
Signs ure Date
I, 1!�Sh 4 k Leal. S P , a Notary Public of the County of 6run Sl,()1 C"r-
State of North Carolina, hereby certify that _ p -j • LZgan appeared
personally before me this day and being duly sworn ackrfowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of ('f,M-)3tr , 20�
Kristine Case
�eal NOTARY PUBLIC
Brunswick County, NC
My Commission Expires August 08, 2026
Notary
My commission expires