NCC221375_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. Atlas Valley & Olympic Harbour at Bluewater Rise
1. Project Name
2. Location of land -disturbing activity: CountyCraven City or Township New Bern
Highway/Street co"nty une Road (SR 1101) Latitude 35.007913 Longitude -77.050757
3. Approximate date land -disturbing activity will commence:April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Clearing & grubbing (fature residential)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):126 acres
6. Amount of fee enclosed: $ $12,600.00 . 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:
NameJohn Thomas
Telephone [phone] Cell It
E-mail Address [e-mail]
252.671.5855 Fax it 252.636.2448
9. Landowner(s) of Record (attach accompanied page to list additional owners):
A. Sydes Construction, Inc. 910.455.0966 910.455.6325
Name Telephone Fax Number
PO Box 7122 100 Carolina Plantations Blvd.
Current Mailing Address
Jacksonville, NC 28540
City
State Zip
Current Street Address
Jacksonville, NC 28546
City State Zip
10. Deed Book No. 3404 Page No. 657 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.
A. Sydes Construction, Inc. [e-mail]
Name E-mail Address
PO Box 7122
Current Mailing Address
Jacksonville, NC 28540
City State Zip
Telephone [phone]
11 . eM
1. 91e •
Current Street Address
Jacksonville, NC 28546
City State Zip
Fax Number 910.455.6325

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:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
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.
Ant ony W. Sydes
r
print name
Signature
President
Title or Authority
Date
I, Lill P ! I�LI , a Notary Public of the County of eqn-5(0 'V
State of North Carolina, hereby certify that jq dp vY v d'e!s:> appeared
personally before me this day and being duly swam a knowledged that the above form was
executed by him. (,.,
Witness my hand and notarial seal, this day of Fe L9KU9 r V, 20_:;�-:Z
,`��yausf ��� MurNUt�fj,,
q�OTAR y. Nota
Seal
My commission expires
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