NCC240717_FRO Submitted_20240320

co Pitt County
is 1Q �'t'�� Planning Department
e Development Services Building
io ' a< 1717 W. 5th Street
4 e °'' Greenville, North Carolina 27834-1696 James F.Rhodes,AICP
Telephone: [phone] Director
Fax: [phone]
Financial Responsibility/Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land-disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable, place N/A in the blank.)
Part A. �W .‘
1. Project Name \'(t N Sau l PIA ^
et, Z
2. Location of land-disturbing activity: County ?i f* ''//
City or Township 1k I A r it ik1 , and Highway/Street K;n a..t L8 oc4541 ai
3. Approximate date land-disturbing activity will be commenced: /
4. Purpose of development(residential, commercial, industrial, etc.): 'r 4,).et,
6. Approximate acreage of land to be disturbed or uncoNered: -3 D ek C res
6. Has an erosion and sedimentation control plan been filed? Yes VNo
7. Person to contact should sedimentation control issues arise during land-disturbing-activity:
Name(4o01 6f-Me( Telephone 252. - ?/7 - i q ig.
8. Landowner(s) of Record (Use blank page to list additional owners):
�C 4.}C LL.C-
Name(s) r �-I� Name(s)
19%0 9. A EA5f rirrrioul tR.ltf)'
Current mailing address 25 Street address
(matndlit pc
City State Zip City State Zip
9. Recorded in Deed Book No. 3FSa Page No. ,S! 2.
Part B.
1. Person(s) or firm(s) who are financially responsible for this land-disturbing activity (Use
the blank page to list additional persons or firms):
Name of person(s)or Firm(s) Name(s)
Current mailing address Street Address
City State Zip City State Zip
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
PCiC
Name(s)
Ito Z Ft 6,K4 F:re1-efoAt ei
Current mailing address Street Address
Gr4-ee , IkG Z?V5c
City State Zip City State Zip
2-6.2 711 Ill?
Telephone Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner(Use blank page to list additional partners):
Name(s) Name(s)
Current mailing address Current mailing address
City State Zip City State Zip
Telephone Telephone
The above information r�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/her attorney-in-fact or if not an individual by an officer, director, partner, or
registered agent with 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. Pc-NC /cj gr des Pi cm e /1114.440er
Ty
p t Title3 of
Authority
R? 12.'ff
s 2
Signature Date
CLUA)1
ryi ,a Notary Public of the County of 1 State
of North Carolina, hereby ce ify that PC i4C C;Ales
appeared personally before me this day and being duly sworn acknowledged that the above form
was executed by him. v� I
Witness my hand and notarial seal this 5 day of i Y 1 tt cJi .20 2 4
.••\SON M'' alikthe
N> "Gomm'e•:U.\ Notary
Q',4; `a',tr1/4'- My comml lion expires /0/0, /2i7 M
NOTARY
PUBLIC