NCC221524_FRO Submitted_20220504

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 NIA in the blank.)
Part A. The Fost Tract Planned Development Residential Phase 2
1. Project Name
2. Location of land -disturbing activity: County Cu rrltuck City or Township Moyock
Highway/Street Survey Rd. (SR1215) Latitude 36deg 29' 57,98" Longitude -76deg 08' 42.70"
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 28
6. Amount of fee enclosed: $ 2,800.00 . 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:
Name Justin Old E-mail [e-mail]
Telephone [phone] cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Moyock Development, LLC [phone]
Name
417 Caratoke Hwy, Unit D
Telephone Fax Number
417 Caratoke Hwy, Unit D
Current Mailing Address Current Street Address
Moyock NC 27958 Moyock NC 27958
City State Zip City State Zip
10. Deed Book No. 1 524 Page No. 456 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party,
Moyock Development, LLC [e-mail]
Name E-mail Address
417 Caratoke Hwy, Unit D 417 Caratoke Hwy, Unit D
Current Mailing Address
Moyock NC 27958
City State Zip
Telephone [phone]
Current Street Address
Moyock NC 27958
City State Zip
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 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:
Justin Old [e-mail]
Name of Registered Agent E-mail Address
417 Caratoke Hwy, Unit D 417 Caratoke Hwy, Unit D
Current Mailing Address Current Street Address
Moyock NC 27958 Moyock NC 27958
City State Zip City State Zip
Telephone [phone] 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.
Justin Old
Type or print name
Sign-afure
Registered Agent
Title or AuthTty
zz
Date
YV j 0 VA-ck-[ , a Notary Public of the County of �G
State of No h Carolina, hereby certify that l/ appeared
personally before me this day and being duly 3worn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of 20�
VV
Oi No ry
AUTARr av,l7 Zo2-3
My commission expires
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