NCC221566_FRO Submitted_20220421

cod, Pitt County
Planning Department
A Development Services Building
a 1717 W. 5th Street
�Aao Greenville, North Carolina 27834-1696 James F. Rhodes, AICP
Telephone: [phone] Director
Fax: [phone]
Financial Responsibility / Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land -disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Arthur Christian Church
2. Location of land -disturbing activity: County pi t-_t
City or Township Bell Arthur , and Highway/Street Bell Arthur Rd.
3. Approximate date land -disturbing activity will be commenced: 6-1-22
4. Purpose of development (residential, commercial, industrial, etc.): church
5. Approximate acreage of land to be disturbed or uncovered: 5.0 Ac .
6. Has an erosion and sedimentation control plan been filed? Yes_ No
7. Person to contact should sedimentation control issues arise during land-disturbingactivity:
Name Ashley Capps Telephone [phone]
8. Landowner(s) of Record (Use blank page to list additional owners):
Arthur Christian Church Trustees
Name(s) Name(s)
_ P_n 'Rnx ,? 9
Current mailing address Street address
Bell Arthur, NC 27811
City State Zip City State Zip
9. Recorded in Deed Book No. 0 0 3 719 Page No. 00567
Part B.
Person(s) or firm(s) who are financially responsible for this land -disturbing activity (Use
the blank page to list additional persons or firms):
Arthur Christian Church
Name of person(s) or Firm(s) Name(s)
PO Box 579
Current mailing address Street Address
Bell Arthur, NC 27811
City State Zip City State Zip
252-916-9385
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner (Use blank page to list additional partners):
Name(s) Name(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone
Telephone
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/her attorney -in -fact or if not an individual by an officer, director, partner, or
registered agent with 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.
Ashley Capps Chairman of Board for Arthur Christian
Ty pint /ntc Title or Authority Church
S nii!
ature Date
a Notary Public of the County of%�J` State
of North Carolina, hereby certify tha(
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 / day of �f�'� 20Z2
Notary •+� ,Z 2�
NQ -o ., My commission expires
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