NCC241905_FRO Submitted_20240621

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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:Branchwood Trace
2. Location of land-disturbing activity: County: Onslow City or Township:Jacksonville
Highway/Street: Onsville Drive Latitude: 34.782 Longitude:-77.417
3. Approximate date land-disturbing activity will commence: Spring/Summer 2024
4. Purpose of development(residential,commercial, industrial,institutional, etc.):Residential
5. Total acreage disturbed: 3.67 Total acreage in Tract: 6.16
6. Amount of fee enclosed: $975.00. The 2012app1ication fee for City of Jacksonville$225.00 for first acre plus$125 for each additional
acre or portion thereof(Example:9.1-acres;application fee=$1,350).Based on ac.in total tract.
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:Dustin T. Mills E-mail Address: [e-mail]
Telephone:[phone] Cell#: 252-916-2691 Fax#:N/A
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Branchwood Trace,LLC 252-751-3669 N/A
Name Telephone Fax Number
P.O.Box 566 631 Dickinson Ave.
Current Mailing Address Current Street Address
Greenville NC 27835 Greenville NC 27834
City State Zip City State Zip
10. Deed Book No.5981 Page No.219 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):
Branchwood Trace,LLC [e-mail]
Name E-mail Address
P.O.Box 566 631 Dickinson Ave.
Current Mailing Address Current Street Address
Greenville NC 27835 Greenville NC 27834
City State Zip City State Zip
Post Office Box 128♦Jacksonville,North Carolina 28541 ♦[phone]♦TDD#[phone]♦Fax[phone]

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Telephone:252-'751-3669 Fax Number:N/A
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:
NiA
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.
Dustin T. Mills Manager
Type or p eupt name Title or Authority
Signature Date
I, -ry "j(„�_ c ,a Notary Public of the County of
State of North Carolina,hereby certify that rn-��C 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 day of 20 c)L1
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Post Office Box 128 a Jacksonville;North Carolina 28541 a(910)938-5245 0'FDD#[phone] a Fax[phone]