NCC221194_FRO Submitted_20220328

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. (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
2.
3.
4.
5.
Project Name Peltier Point
Location of land -disturbing activity: County Carteret City or Township Morehead City
Highway/Street South Shore Drive Latitude 34°43'33.31" Longitude -76°46'56.43"
Approximate date land -disturbing activity will commence: 9/20/2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.55 ac
6. Amount of fee enclosed: $ 195.00 . 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 Thomas F. Bell, Manager/Member E-mail Address [e-mail]
Telephone [phone]
Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bell Investment Group, LLC 919-580-6247
Name
408 Tryon Drive
Current Mailing Address
Goldsboro NC 27530
City
10. Deed Book No. 1704
Part B.
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
Page No. 67 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):
Bell Investment Group, LLC [e-mail]
Name E-mail Address
408 Tryon Drive
Current Mailing Address Current Street Address
Goldsboro NC 27530
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
Current Mailing Address
City
Telep
E-mail Address
Current Street Address
State Zip 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
State
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.
Thomas F. Bell
Type on ; name
Signature
Manager/Member
Title or Authority
Date
I, I )a �,en Q . %. Iye,e 0Apx a Notary Public of the County of OaA f ycl
State of North Carolina, hereby certify that T1,iffriS E appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this Zl9 day of P\��' 20 2t
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