NCC223861_FRO Submitted_20221118

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Jack's Branch Townhomes
2. Location of land -disturbing activity: County Onslow City or Township Hubert
Smallwood Rd. 34,677065-77.189763
Highway/StreetLatltude(decimal degrees) Long)tude(decimal degrees)
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.38
6. Amount of fee enclosed: $ 300.00 . 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).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes N Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Elijah Morton E-mail Address [e-mail]
Phone: Office # 910-548-7575 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
South State Development, LLC 910-548-7575
Name
121 Garnet Lane
Current Mailing Address
Jacksonville NC 28546
City State
10. Deed Book No. 5745
Phone: Office # Mobile #
121 Garnet Lane
Current Street Address
Jacksonville NC 28546
City State Zip
202 Page No. Provide a copy of the most current deed.
Zip

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
South State Development, LLC
Company Name
121 Garnet Lane
Current Mailing Address
Jacksonville NC 28546
[e-mail]
E-mail Address
121 Garnet Lane
Current Street Address
Jacksonville NC 28546
City State Zip City
Phone: Office # 910--548-7575 Mobile #
State
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Elijah Morton
Name of Registered Agent
121 Garnet Lane
Current Mailing Address
Jacksonville NC
City
[e-mail]
E-mail Address
121 Garnet Lane
Current Street Address
28546 Jacksonville NC 28546
State Zip City
Phone: office # 910-548-7575 Mobile # [phone]
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

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
Telephony;
Zip City
Fax Number
State Zip
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.
Elijah Morton
Type or print name
r [gna re _
Member
Title or Authority
Date
I, k= jtZCe,64C Y'A- C aQG rt a Notary Public of the County of CO, r-kri-:6
State of North Carolina, hereby certify that F k.Na�1' iA.o c -V&n appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my
rial seal, this Z9 day of , 20 U
Nota
My commission expires