NCC232573_FRO Submitted_20230829

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 Gate Stone Subdivision Section 11
2. Location of land-disturbing activity: County Onslow City or Township Jacksonville
Highway/Street NCSR 1110 Latitude 34°42'47.328" Longitude 77°32'13.158"
3. Approximate date land-disturbing activity will commence: July 1, 2020
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.20 acres
6. Amount of fee enclosed: $ 325.00 . 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 XX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John L. Pierce E-mail Address [e-mail]
Telephone [phone] Cell# N/A Fax# [phone]
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Gate Stone LLC [phone] [phone]
Name Telephone Fax Number
P.O. Box 1685 405 Johnson Blvd.
Current Mailing Address Current Street Address
Jacksonville NC 28541 Jacksonville NC 28540
City State Zip City State Zip
10. Deed Book No. 4994 Page No. 848 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):
Gate Stone LLC [e-mail]
Name E-mail Address
P.O. Box 1685 405 Johnson Blvd,
Current Mailing Address Current Street Address
Jacksonville NC 28541 Jacksonville NC 28540
City State Zip City State Zip
Telephone [phone] Fax Number [phone]

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 nerne, attach m copy of the Certificate of Assumed Name. If the Financially Responsible
Party iaa 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 aftorney-in-foot, orifnot an individua|, by on ofhoer, director, padner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there be any change in the information provided herein.
Betty Bullock Manager
Type or print name Title orAuthority
May 27. 2O2D
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�Vgnu/u/e Date
a Notary PuNk: ofthe Countvof
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State of North Carolina, hereby certify that e/ a Ad[�/c appeared
pereune||v before ma this day and being duk/ oxvomn acknowledged that the above form was
executed bvhim.
Witness my hand and notarial meo[ this '/''day of y y /:�f / / . 2096
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My commission expires T" IT I'O'l-t