NCC241098_FRO Submitted_20240424

N&T#18138
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 Dollar General Willard Pender County
2. Location of land-disturbing activity: County _Pender City or Township Union
Highway/Street Hwy 11 Latitude 0 Longitude
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Commercial
5. Total acreage disturbed or uncovered(including off site borrow and waste areas): 2 T13 3,0
6. Amount of fee enclosed: $ $195,00 .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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name J. Phillip Norris, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 910-471-9638 Fax# [phone]
9, Landowner(s)of Record(attach accompanied page to list additional owners):
Kenneth L.West 919- 920-9326
Name Telephone Fax Number
112 Hood Dr. 112 Hood Dr.
Current Mailing Address Current Street Address
Goldsboro NC 27530 Goldsboro NC 27530
City State Zip City State Zip
10. Deed Book No. 543 Page No. 58 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):
Rudy L. Pittman, Managing Member
Par 5 Development Group, LLC [e-mail]
Name E-mail Address
2075 Juniper Lake Road 2075 Juniper Lake Road _
Current Mailing Address Current Street Address
West End NC 27376 West End NC 27376
City State Zip City State Zip
Telephone [phone] Fax Number 910-944-0882

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:
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.Rudy L. Pittman R,1, J) r 71h Managing Member
Type or print name Title or Authority
Signat — dell/"4 11
I, 5510 5 CO* ,a Notary Public of the County of MOO V(
State of North Carolina, hereby certify that d 1—,* Pt 4' 'v to n
appeared personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
I
Witness my hand and notarial seal,this day o�f 1 20 iq
Seal Notary
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