NCC242460_FRO Submitted_20240820

WILSON
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: Bloomery Forest
PROJECT LOCATION: 4269 &4246 Raleigh Road Parkway
APPROXIMATE PROJECT START DATE: July 1 , 2023
(#)ACRES TO BE DISTURBED 48.00 X$150.00/ACRE= $7,200
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.)
David Chapman - Southbury Development, LLC
Name(Person or Firm)
20 Cochrane Castle Circle
Street Address(No P.O.BOX)
Pinehurst, NC 28374
City,State,Zip
760-567-5039
Telephone#
NA
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
NA
Name(Person or Firm)
NA
Street Address(No P.O.BOX)
NA
City,State,Zip
NA
Telephone#
NA
Fax#
NA
E-mail address
PROJECT NAME: Bloomery Forest

WILSON
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
David Chapman - Southbury Development, LLC 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.)
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Date
Mevek
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Signature
`-Davi a Chaprrotivi
Type or Print Name
Mein el ldi ail
Title Date
I►' 61,-('YI 4}po 4 ,a Notary Public of the County of f(le- ,
State of North Carolina hereby certifies
�!W I a l l i AA,. personally appeared before me this day and under
oath acknowledged that the above form was executed by him. (—
Witness my handt\ld otary seal,t ' I. day of A�(AS T ,
(Notary Public) /rl)�!* \``\ooloO �,'''
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My commission expir /d / ! 4.4'
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