NCC222049_FRO Submitted_20220601

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM NT22018 &
SEDIMENTATION POLLUTION CONTROL ACT NT20087
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. Isabella Park
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Northwest
Highway/Street US 74 Latitude 34.2838 Longitude-78.1322
3. Approximate date land -disturbing activity will commence: March 10, 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: $ Previously Paid $1,820.0.0 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 910-471-9638 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Q Hickory Holdings, LLC 470-681-6469
ty
Name Telephone Fix Number
3348 Peachtree Road NE, Ste 1460 3348 Peachtree Road NE, Ste A60
Current Mailing Address Current Street Address
Atlanta GA 30326-1497 Atlanta GA 30326-1497
City State Zip City State Zip
10. Deed Book No. 4765 Page No. 366 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.
Q Hickory Holdings, LLC [e-mail]
Name E-mail Address
3348 Peachtree Road NE, Ste 1460
Current Mailing Address
Atlanta GA 30326-1497
City State Zip
Telephone [phone]
3348 Peachtree Road NE, Ste 1460
Current Street Address
Atlanta GA 30326-1497
City State Zip
Fax Number NIA

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:
CT Corporation System
Name E-mail Address
160 Mine Lake Ct_ Ste 200 160 Mine Lake Ct. Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
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,
James Howley
ame
Authorized Signatory
Title or Authority
Date
I, ►�1�' r �' �l a Notary Public of the County of O_j 4 b
State of North Carolina, hereby certify that G4--4"Q-;::S L—'�-s-� appeared
personally before me this day and being duly sworn acknowledged that above form was
executed by him.
Witness my hand and notarial seal, this C�5
Seal
day of ��(,� r a 20 <�—)
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