NCC242470_FRO Submitted_20240820

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Sanders Community Phase 1
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure(DWI).
N/A
2. Location of land-disturbing activity: CountyOnSIOW City or Township Swansboro
Bear Creek Road 34.653 Rude decimal degrees)-77.207
Highway/Street Latltude(decimal degrees) Lon g (
3. Approximate date land-disturbing activity will commence: July 2024
Residential
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 31.8
6. Amount of fee enclosed: $ 3200 . The application fee of$100.00 per acre(rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed px No ❑x
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jonathan McDaniel E-mail Address [e-mail]
Phone: Office# 252-393-6101 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Sanders Zeta Tolson Trustee na na
Name Phone: Office# Mobile#
342 Stewart Point Road Bear Creek Road & 110 Stewart Point Road
Current Mailing Address Current Street Address
Hubert NC 28539 Hubert NC 28539
City State Zip City State Zip
10. Deed Book No.1624 Page No.535 Provide a copy of the most current deed.
1309 84

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies).
Can't Be Did, LLC [e-mail]
Company Name E-mail Address
342 Stewart Point Road 342 Stewart Point Road
Current Mailing Address Current Street Address
Hubert NC 28539 Hubert NC 28539
City State Zip City State Zip
Phone: Office#na Mobile# 990"330-497$
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Gloria Sanders [e-mail]
Name of Registered Agent E-mail Address
342 Stewart Point Road 342 Stewart Point Road
Current Mailing Address Current Street Address
Hubert NC 28539 Hubert NC 28539
City State Zip City State Zip
Phone: Office# na Mobile# [phone]
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Gloria Sanders Managing Member
Typ r print nam Title or Authority
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ivai
Sign ture Date
I, AN\ 1 •\�% -1 S , a Notary Public of the County of Ore-A-€.
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State of North Carolina, hereby certify that ufl Cl., appeared personally
before me this day and being duly sworn ackno dged that the above form was executed by him/her.
Witness\\r\r�XlhAriJif?nd notarial seal, this 31- k day of 20 D L)
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Sander Zeta Trustee & William na na
Name Phone: Office# Mobile#
342 Stewart Point Road 282 The Camp Road
Current Mailing Address Current Street Address
Hubert NC 28539 Hubert NC 28539
City State Zip City State Zip
Deed Book No. 1 266 Page No, 390 Provide a copy of the most current deed.
Landowner 3 of Record:
Heller Sarah Sanders na na
Name Phone: Office# Mobile#
5000 Harbour Ridge Drive Stewart Point Road
Current Mailing Address Current Street Address
Alpharetta GA 30005 Hubert NC 28539
City State Zip City State Zip
Deed Book No.1093 Page No.258 Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
{
( City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.