HomeMy WebLinkAboutNCC223653_FRO Submitted_20221025FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Zaz2
SEDIMENTATION POLLUTION CONTROL ACT I:
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 a -mail and/
or fax information unavailable, place NIA in the blank.)
A.
1. Project Name Heartwood Drive Culverts
1. P
2. Location of land -disturbing activity: County Brunswick City or Township Leland
Highway/Street Heartwood Drive Latitude 34.189556 Longitude-78.004333
3. Approximate date land -disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.42
6. Amount of fee enclosed: $ 100 . 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:
NameDoky Saffo E-mail Addressdokysaffo@gmail.com
Telephone 910-264-3627 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mallory Creek Land & Timber Inc
Name Telephone Fax Number
PO Box 3649 Mallory Creek Drive
Current Mailing Address Current Street Address
Wilmington NC 28406 Leland NC 28479
City State Zip City State Zip
10. Deed Book No. 01 1 92 Page No. 0764 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.
Brunswick Pines Inc lucienellison@gmail.com
Name E-mail Address
5917 Oleander Drive Suite 108
Current Mailing Address
Wilmington NC 28403
City State
Telephone 910-264-3627
Zip
Current Street Address
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:
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.
Lucien C. Ellison Vice President
Typint ame Title or Authority
r7S"hZature Date
k� ;% to M S , a Notary Public of the County of �
State of North Carolina, hereby certify that LAC i en C. ESon 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 of2D2-
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Notary
ONew BAR O A WILLIAMS��3�a�a�
Notary Public My commission expires
North Carolina
Hanover County