HomeMy WebLinkAboutNCC233522_FRO Submitted_20231129 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 Finley Farms Subdivision
2. Location of land-disturbing activity: County Brunswick City or Township Town Creek
Highway/Street Springstone Drive Latitude 34.2118 Longitude -78.0601
3. Approximate date land-disturbing activity will commence: project is ongoing per BRUNS-2017-057
4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.9 (6.2 new)
6. Amount of fee enclosed: $ 0 (transfer only) . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Bowser E-mail Address sbowser(c�mungo.com
Telephone 910-409-0211 Cell # _ Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Clayton Properties Group, Inc. 910-409-0211
Name Telephone Fax Number
211 Racine Drive, Suite 101 211 Racine Drive, Suite 1.01
Current Mailing Address Current Street Address
Wilmington NC 28403 Wilmington NC 28403
City State Zip City State Zip
10. Deed Book No. 4547 Page No. 890/893/ 896 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):
Clayton Properties Group, Inc. sbowser(a�mungo.com
Name E-mail Address
211 Racine Drive, Suite 101 211 Racine Drive, Suite 101
Current Mailing Address Current Street Address
Wilmington NC _ 28403 Wilmington NC 28403
City State Zip City State Zip
Telephone 910-409-0211 Fax Number
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:
Scott Bowser sbowsermungo.com
Name of Registered Agent E-mail Address
211 Racine Drive, Suite 101 211 Racine Drive, Suite 101
Current Mailing Address Current Street Address
Wilmington NC 28403 Wilmington NC 28403
City State Zip City State Zip
Telephone 910-409-0211 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.
Scott Bowser Assistant Secretary, Clayton Properties Group, Inc.
Type or print name Title or Authority
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Signat a Date
I, tom\ , a Notary Public of the County of N-QA n ovc
State of North Carolina, hereby certify that SC-04 gDWSe-r 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 2-9 day of Marik , 20 i-I
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