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HomeMy WebLinkAboutNCC233520_FRO Submitted_20231205 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 TJ's Transient Marina 2. Location of land-disturbing activity: County Beaufort City or Township Pantego Highway/Street 975 Pantego Street Latitude 35.538966° Longitude-76.609884° 3. Approximate date land-disturbing activity will commence:October 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.0 6. Amount of fee enclosed: $ 300'00 . The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00). 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 Tobin Tetterton E-mail Address tobin@rsnet.org Telephone(252) 943-6677 Cell# (252) 944-5555 Fax# 9. Landowner(s)of Record (attach accompanied page to list additional owners): TJ Land Development LLC (252) 944-5555 Name Telephone Fax Number P.O. Box125 Current Mailing Address Current Street Address Pantego, NC 27860 City State Zip City State Zip 10. Deed Book No.2067, 2086,2108 Page No.710,609, 831 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 maybe listed as the financially responsible party. Tobin J. Tetterton tobin@rsnet.org Name E-mail Address P.O. Box 125 Current Mailing Address Current Street Address Pantego, NC 27860 City State Zip City State Zip Telephone(252) 944-5555 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: N/A 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: N/A 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. � 0 b n tJ� - L r 1a� �Q In Q e r' i e e r y or print name Title or Authorit� Signatu Date IPh 111,s(Ba rl.1,: ( (h O 0[led , a Notary Public of the County of (/ e C U't`0/1 State of North Carolina, hereby certify that:A T Tt2 Lo►'TO appeared personally before me this day and being uly sworn acknowledged that the above form was executed by him. Witness r ,,,,,,d and notarial seal, thi 27 day of Ai juiSt , 24 3 LL) =ri e Notary Se�l / (' /� OC AUg rut w My commission expires Ty/ �'S, 1�A �Du+jy� lt a .�k1�.�1 j� in✓' Q�b � `�A