NCC231953_FRO Submitted_20230626

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 Oak Grove(a) Blake Farm
2. Location of land-disturbing activity: County Pender City or Township Topsail Township
Highway/Street US HWY 17 Latitude 34° 19' 31"N Longitude 77°45' 54"W
3. Approximate date land-disturbing activity will commence: October, 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11.0
6. Amount of fee enclosed: $ 715.00 . The application fee of $65.00 per acre (rounded up to the
next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585).
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:
Name Madison Robideau E-mail Address madison(atrasklandco.com
Telephone [phone] Cell# 910-599-0558 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Edisto Senior Real Estate, LLC 910-799-8755 910-799-8785
Name Telephone Fax Number
1022 Ashes Drive, Suite 201
Current Mailing Address Current Street Address
Wilmington NC 28405
City State Zip City State Zip
10. Deed Book No. 4775 Page No. 1604-1605 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):
Trask Land Company, Inc. raiford(ctrasklandco.com
Name E-mail Address
1022 Ashes Drive, Suite 201
Current Mailing Address Current Street Address
Wilmington NC 28405
City State Zip City State Zip
Telephone [phone] Fax Number 910-799-8785

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.
dolt-
Raiford G. Trask, Ill .MaRacier--Trask Land Company, Inc.
Type or pri e Title or Authority
Signa ure Date
I, \ -e+ iG w , a Notary Public of the County of t°42 rdinoi&
State of North Carolina, hereby certify that 2t& (Di _ (: T Z& --(l i 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 ZA day of 0) , 20
MA171SCN RQgIDEAIJ
Ne�TA�RY PUBLIC Notary
nover County
North Carolina My commission expires .130/12-
My Commission Expires Aug.30,2022

Permission to Work on and Enter on Land
I certify that I am authorized to grant and do in fact grant permission to Trask Land Company
to do the work on the land zuestion as authorized by this permit, and to the Erosion Control
Inspection and his .g-nt-'to e ter on the land in question in connection related to this permit.
f Blake Farm North Commercial, LLC (7/X ))---'
Signature P Entity Dat