NCC230184_FRO Submitted_20230124

(ATTACHMENTA)
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.
1. Project Name: S 1 , L� �`. S
2. Location of land -disturbing activity: Onslow County City or Township: City of Jacksonville
Highway/Street: - ti s A-, 3 \ , A . Latitude: 340 Longitude: 770
3. Approximate date land -disturbing activity will commence: 1 /z (./2.3
4. Purpose of development (residential, commercial, industrial, institutional, etc.): co.,., .M
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 3 SSo , o 0
The application fee of $225.00 for the first acre plus $125 for every additional acre (rounded up to the
next acre) is assessed without a ceiling amount. (Example: 6.4-acre application fee is $975).
7. Has an erosion and sediment control plan been filed? Yes ® No ❑ Enclosed ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name: N.,- (Ihs,,bk�as E-mail Address: na,,,.,,_, 4�R �� I �k:ss-rINb:1-�o�
Telephone #: Z S Z - Re-3 -4 -� I- Cell #: Fax #:
9. 1 06 r-34-• r Apt. I(D b j-=sh-. i AFL
Current Mailing Address Current Street Address
c1'--�'1-1- N(' ZS203 ('L., ,l.-L4 8z03
City State Zip City State Zip
10. Deed Book: Ss. 3 3 Page Number: \ - (Provide a copy of the most current deed)
Part B.
1. 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):
t .:n ru✓ - C vM
Name -mail Address'
1 0 6 F-e sk`, A
Current Mailing Address
1 D (_ !F- z -4-< -- A
Current Street Address
C ,l.-4L riL_ Z,9Zo'; C C- 2°20
City State Zip City State Zip
Telephone #: -7oL� - 3i � -9332 Cell #: Fax #:

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone #:
State Zip
Cell #:
E-mail Address
Current Street Address
City
Fax #:
State Zip
(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
Current Mailing Address
City
Telephone #:
State Zip
Cell #:
E-mail Address
Current Street Address
City
Fax #:
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.
Pr
Type or print name Title or Authority
2-023
Signature Date
I, Oav�a�a n O rOn ,a Notary Public of the County of Q6&W1} &O
State of North Carolina, hereby certify that C YfYMA appeared personally
before me this day and being duly sworn acknowledged that the ab v form was executed by him.
Witness my hand and notarial seal, this JOH"� day of
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