NCC233769_FRO Submitted_20231222

•
WILSON
H (AY
Financial Responsibility-Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson
Sedimentation and Erosion Control Ordinance before completing and filing this form with the City of
Wilson Erosion Control Division. (*Indicate N/A if a question is not applicable)
PROJECT NAME: TIDAL WAVE AUTO SPA WILSON
PROJECT LOCATION:2901 RALEIGH ROAD PARKWAY
APPROXIMATE PROJECT START DATE:10/15/2023
(#)ACRES TO BE DISTURBED 2.03 x$150.00/ACRE= $304.50
Person(s)or Firm(s)financially responsible for this land disturbing activity:(If out of state,a registered
agent in North Carolina must be used.)
SHJ DEVELOPMENT LLC
Name(Person or Firm)
124 E Thompson St
Street Address(No P.O.BOX)
Thomaston, Georgia 30286
City,State,Zip
478-972-2418
Telephone#
Fax/!
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
CT Corperation System
Name(Person or Firm)
160 Mine Lake CT, STE 200
Street Address(No P.O.BOX)
Raleigh, North Carolina 27615
City,State,Zip
478-972-2418
Telephone#
Fax/!
[e-mail]
E-mail address
PROJECT NAME: TIDAL WAVE AUTO SPA WILSON

WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
MARTIE MURPHY or
Financially Responsible Person Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by
me while under oath.(This form must be signed by the Financially Responsible Person if an individual or
by an officer,director,partner,and attorney-in-fact,or other person with authority to execute
instruments for the financially responsible person if not an individual.)
12/19/2023
Date
DIRECTOR OF ENTITLEME
Title or Auti7�
11
Signature
MARTIE MURPHY
Type or Print Name
21I °1 � 2,�23
Title Date
0242/1//,' a Notary Public of the County of 11/
State of hereby cerh'fies
Lip
personally appeared before me this day and under
oath acknowledged that the above form was execc/u� by him.
Witness my hand and otary seal,this / /wday of DC.e../44/LA.ri
(Notary Public)
+,,�Itlf'�. .
My commission expires '��, + `(N C�
Ey,p,RES
GEORGIA
',.2Z
ii,S:O N CO 0
04
"t f t VO