NCC222627_FRO Submitted_20220725

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 Environment and Natural Resources. (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.
Project Name Cherry Tree Place
2. Location of land -disturbing activity: County Brunswick City or Township Northwest
Highway/Street 2583 Mt. Misery Road Latitude 34' 17' 25" N Longitude 78' 03' 25" W
3. Approximate date land -disturbing activity will commence: August, 2022
4. Purpose of development (residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.0 ac
6. Amount of fee enclosed: $ 1,100.00 The application fee of $65.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount plus Express Fee of $250.00 per acre up to 8
acres. (Example: a 9-acre application fee is $585+$2,000=$2,585).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steven Shuttleworth E-mail Address stevea-steveshuttleworth.com
Telephone [phone] Cell # 719-499-1373 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J & S Land Development, LLC
Name
8620 River Road
Current Mailing Address
Wilmington North Carolina 28412
City State Zip
719-499-1373
Telephone Fax Number
8620 River Road
Current Street Address
Wilmington, North Carolian 28412
City State Zip
10. Deed Book No. 4756 Page No. 0387 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
J & S Land Development, LLC
Name
8620 River Road
Current Mailing Address
Wilmington North Carolina 28412
City State Zip
steveasteveshutlleworth.com
E-mail Address
8620 River Road
Current Street Address
Wilmington NC 28412
City State Zip

Fax Number
Telephone [phone]
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 State Zip
T
E-mail Address
Current Street Address
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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 by any change in the information provided herein.
Manag -I Member of J & S„Land Development, LLC
Title or Authority
Z-/—
Date
0-Y-' a Notary Public of the County of nbo kv
State of North Carolina, hereby certify that ]ek 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 r� J 20 z Z
Notary
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