NCC231702_FRO Submitted_20230613

(ATTACHMENT A)
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: Mt. Sinai Holy Church
2. Location of land-disturbing activity: Onslow County City or Township: City of Jacksonville
Highway/Street: Country Club Road Latitude: 34°46'08.2" Longitude: 770 23'15.8"
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Other
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.1
6. Amount of fee enclosed: $ 350.00
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: Cynthia S. Gray E-mail Address: [e-mail]
Telephone #: (757) 839'1822 Cell #: Fax #:
9. 1012 Country Club Road 1012 Country Club Road
Current Mailing Address Current Street Address
Jacksonville NC 28546 Jacksonville NC 28546
City State Zip City State Zip
10. Deed Book: 4680 Page Number: 923 (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):
Mt. Sinai Holy Church, Inc. [e-mail]
Name E-mail Address
1012 Country Club Road 1012 Country Club Road
Current Mailing Address Current Street Address
Jacksonville NC 28546 Jacksonville NC 28546
City State Zip City State Zip
Telephone #: [phone] Cell #: Fax #:

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #: Cell #: Fax #:
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #: _ Cell #: Fax #:
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.
Cynthia S. Gray Pastor
Type or print name Title or Authority
0 ,k.),4,44..... ),A Id 3/a 8/ a-3
Signat Date
YI, �j p c$o' ,a Notary Public of the County of �J► 1 l c 1�
State of North Carolina, hereby certify that y\ V\l S . GrckLi appeared personally
before me this day and being duly sworn acknowl ed that the above form was executed by him.
my d t�'$ i a�-o! _ day of Y\OiA C..Qi� 20 .23
•Witness han .�r� oar �� f/this
IriTh
Notary
S I
PUBS-S� =U� My commission expires 9o �
"'iliin'"