NCC221365_FRO Submitted_20220413

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. VINEYARD TRAILS PHASE 1
1. Project Name
2. Location of land -disturbing activity: County ONSLOW City or TownshipN/A
3
Highway/Street GUM BRANCH ROAD Latitude34°51'1.47" N Longitude77028'29.89° W
Approximate date land -disturbing activity will commence:2/28/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):65
6. Amount of fee enclosed: $ 6500 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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:
NameSTEVE SHUTTLEWORTH E-mail [e-mail]
Telephone [phone]
Cell # 719-499-1373 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J&S LAND DEVELOPEMENT LLC 919-624-0564
Name
8620 RIVER ROAD
Current Mailing Address
WILMINGTON, NC 28412
City State
10. Deed Book No.5651
Telephone Fax Number
8620 RIVER ROAD
Current Street Address
WILMINGTON, NC 24812
Zip City
Page No.257 & 264
State
Zip
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.
J&S LAND DEVELOPEMENT LLC [e-mail]
Name
8620 RIVER ROAD
E-mail Address
8620 RIVER ROAD
Current Mailing Address Current Street Address
WILMINGTON, NC 28412 WILMINGTON, NC 28412
City
State Zip City
Telephone[phone] Fax Number
State
Zip

Witness my hand and notarial seal, this
-
EXP'res
c al
oi-o
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
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
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone Fax Number
State Zip
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.
Steve Shuttleworth Managing Member
Typ r int Title or Authority
/ _ ' UZZ
Signature Date'
a Notary Public of the County of
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him. �%
"' 7 day of 4 20 ;�D
Notary '
My commission expires DJ CI i�c [� 2-0 Z�
vex
--leC/V�- �1 ll X1IC INU1 -k" 1 appeared
duly sworn acknowledged that the above form was