NCC223274_FRO Submitted_20220921

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.
1. Project Name Maco Road Subdivition
2. Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street 1,800 Wilbur McKeithan way Latitude 34.1915 N Longitude 78.0805 W
3. Approximate date land -disturbing activity will commence: As soon as permitted
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 84 acres
6. Amount of fee enclosed: $ 8,400.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name James Stariha
Telephone [phone] Cell #
E-mail Address
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Clayton Properties Group, Inc.
Name
PO Box 4098
Current Mailing Address
Maryville, TN 37802
City State Zip
[phone]
Telephone
5000 Clayton Road
Current Street Address
Fax Number
Maryville, TN 3780
City State Zip
10. Deed Book No. 4672 Page No. 0663 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.
Clavton Properties Group. Inc
Name
PO Box 4098
Current Mailing Address
Marvville. TN 37802
City State Zip
Telephone [phone]
E-mail Address
5000 Clayton Road
Current Street Address
Maryville, TN 3780
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:
CT Corporation System
Name
160 Mine Lake Court, Suite 200
Current Mailing Address
Raleigh, NC 27615
City State Zip
Telephone
E-mail Address
160 Mine Lake Court, Suite 200
Current Street Address
Raleigh, NC 27615
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
E-mail 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.
Seol+ Voweer
Tvoe-or--orint name
AsSI'AAPIr Sec('6(' ►
Title or Authority
feb (-aarf ol_� 292-2
Date
I, M`' ✓� ��� a Notary Public of the County of 0.0 �1° mv-cr
State of North Carolina, hereby certify that `> ( ff� F O W �r 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 6 day of 1r1tiGl ►Z/ , 20 ZZ
Seal : Notary Public
New Hanover County
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My commission expires b ut . I L t LO Z y