NCC221372_FRO Submitted_20220407

FINANCIAL RESPONSIBILITYIOWNERSHIP 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, NI;. Department of Environmental Quality. Submit the completed form to the appropriate
Regionaf Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavalla le, place N/A in the blank.)
Part A.
1. Project Name F nloch Chase Subdivision
2. Location of laid -disturbing activity: County Wayne City or Township Nahunte
Highway/Stre atGoy Aycock Rd Lcgtitude(decimardegmes)35.5209 Longlt€1de(decimEe degrees)-77.9735
3. Approximate Jate land -disturbing activity will commence: Mar 22
4_ Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 54 ac
6. Amount of fee enclosed: $ 5,400 . The application fee of $100.00 per acre (rounded
up to the ne t acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed J No G
8. Person to cor tact should erosion and sediment control issues arise during land -disturbing activity:
Name Stacy Johnson E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s of Record (attach accompanied page to list additional owners):
J & N DeVE11opers, LLC _ 919.921-2642
Name Phone: Office # Mobile #
PO Box 658 501 South Pearl St.
Current Maili a ,address Current Street Address
Princeton
City
10. Deed Book
NC 27569
Princeton NC 27569
State Zip City State Zip
).3591 Page No. 804-012 Provide a copy of the most current deed,

Pai
1.
Nc
the
co
2.
t B.
Company(ies)
ho are financially responsible fc
of all responsi
le parties on accompanied page
an individuat(s),
the name(s) of the owner(s) may be
J & N DevElopers,
LLC
Company Naine
PO Box 65
Current Mailing
Address
G -t5 9
City
State Zip
Phone: Off ic
# qjq - (i1- B®(0-7
te: If the Financially
Responsible Party is not th
landowner's si
ned and dated written consent fc
itrol plan and tc
conduct the anticipated land dis
(a) If the Financially
Responsible Party is a dom
business regis
ry, give name and street addres
Stacy Johnson
Name of Regist
red Agent
PO Box 658
Current Mailing
Address
Princeton
NC 27569
City
State Zip
Phone: Office
NIA
Name of Individ
jal to Contact (if Registered AgE
(b) If the Financially
Responsible Party is not a
of the designated
North Carolina agent who is r
N/A
Name of Registrared
Agent
Current Mailing
Address
City
State Zip
Phone: Office
Name of Individ
al to Contact (if Registered Age
�r the land -disturbing activity (Provide a comprehensive fist
,) if the company is a sole proprietorship or it the landowner(s) is
listed as the financially responsible party(ies).
stacvQandndeveiotaers.com
E-mail Address
501 South Pearl St
Current Street Address
Princeton NC 27569
City State Zip
Mobile # [phone]
e owner of the land to be disturbed, include with this form
�r the applicant to submit a draft erosion and sedimentation
curbing activity.
astir company registered on the NC Secretary of State
s of the Registered Agent:
stacv ..iandndeveioDers.com
E-mail Address
591 South Pearl St.
Current Street Address
Princeton NC 27569
City State Zip
Mobile # [phone]
nt is a company)
resident of North Carolina, give name and street address
egistered on the NC Secretary of State business registry:
E-mail Address
Current Street Address
City State Zip
Mobile #
nt is a company)

M If the Firian ially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DBA Name
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 individuai(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Type or
M
Title
Ma naa i na A
idar
. ALAhorq
Date
a Notary Public of the County of 'Ao)a n
State of North Ca lina, hereby certify that S Gnw 3os appeared personally
before me this da and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of
eri
r
,,,* Off. . •.�SPri9e�� Notary
�R. W • O i
• � � �"➢'`r.�`;Gil •• A �.
SOT }� /Y My commission expiresC a
o� AUB 00 '�`