NCC233048_FRO Submitted_20231017

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 Environmental Quality. Submit the completed form to the appropriate
Regional Office. (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 SQUIRES RUN VILLAGE
2. Location of land-disturbing activity: County Onslow City or Township Richlands
Highway/Street Cow Horn Road Latitude 34.9075 Longitude-77.5264
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):64.24
6. Amount of fee enclosed: $N/A The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Elijah T. Morton E-mail Address [e-mail]
Telephone [phone] Cell# N/A Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners):
South State Development, LLC 910 548-757 I /A
Name Telephone ax Number
121 Garnet Lane 121 Garnet Lane
Current Mailing Address Current Street Address
Jacksonville, NC 28540 Jacksonville, NC 28540 u
City State Zip City State Zip
10. Deed Book No.5707 Page No.659 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
South State Development, LLC [e-mail]
Name E-mail Address
121 Garnet Lane 121 Garnet Lane
Current Mailing Address Current Street Address
Jacksonville, NC 28540 Jacksonville, NC 28540
City State Zip City State Zip