NCC232611_FRO Submitted_20230912

FINANCIAL RESPONSIBILITYIOWNERSHUP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one m more acres as covered by the Act before this
form and on acceptable erosion and sedimentation nordno| plan have been completed and approved by the
Land C>um!dy Section, N.O. 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 Cotton Hill Subdivision, Section 3
2. Location nf land-disturbing activity: County Ona|mw City orTownship Jacksonville
Highway/Street NCSR142B Latitude 34045'06^ Longitude 77" 1410^
3. Approximate date land-disturbing activity will commence: Oenember2O21
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 51.0
8. Amount nf fee enclosed: $ 3.315 . The application fee of*G5.OU per acre (rounded
upto the next acre)ie assessed without a ceiling amount (Examp!e: oS-oome application fee ia$585).
7. Has an erosion and sediment control plan been filed? Yee X No Enclosed %
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Betty Bullock E-mail Address
Telephone 910'346-8800 Cell# FaV#
B. Landowner(s)of Record(attach accompanied page to list additional owners):
Beaver Creek Investors . Inc. 910-346-8800
Name Telephone Fax Number
PO Box 1885 4OS Johnson Blvd
Current Mailing Address Current Street Address
Jacksonville NC 28541 Jacksonville NC 28540
city State Zip city Stabs Zip
10. Deed Book No. 5407 Page No. Q71-A77 Provide m copy of the most current deed.
Part B.
1. Person(a) or firm(s) who are hnonoia|k/ responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties onon attached aheet):
Beaver Creek Investors, Inc. 8edyB@jlpno.00nm
Name E-mail Address
P.O. Box 1085 4O8 Johnson Blvd
Current Mailing Address Current Street Address
Jacksonville NC 28541 Jacksonville NC 28540
City State Zip City Gbde Zip
Telephone 910-346'9800 Fax Number 910-346-1210

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.
Betty Bullock President
Type • int na Title or Authority
I ;a/ /9//-3/z1
Signature Date
I, evo F a✓d��`v'. , a Notary Public of the County of Q SIOli)
--3State of North Carolina, hereby certify that /J L/t , appeared
personally before me this day and being duly swdrn acknowledged that the above form was
executed by him. 77 >
Witness my hand and notarial seal, this . day of C/E D`Per. , 20A.
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nsiow County My commission expires 9 4 2.6 2-4
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