NCC243060_FRO Submitted_20241009

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 Environmental Quality. Submit "le completed form to the appropriate
Regional Office. (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 QUEENS BLUFF
2. Location of land-disturbing activity: County OnSIOw City or Township Hubert
Highway/Street Queens Creek Road Latitude 34.6729° Longitude -77.1877'
3. Approximate date land-disturbing activity will commence: _ - -
4. Purpose of development(residential, commercial,industrial, institutional,etc.):Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 12.6
6. Amount of fee enclosed: $1,300.00 . 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).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dominick Butch E-mail Address [e-mail]
Telephone [phone] .. Cell# Fax# -
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Lighthouse Realty Holdings, LLC 910 346-2067
Name Telephone Fax Number
814 New Bridge Street, Suite D 814 New Bridge Street
Current Mailing Address Current Street Address
Jacksonville NC 28540 Jacksonville NC 28540
City State Zip City State Zip
10. Deed Book No.5859 Page No.818 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager maybe listed as the financially responsible party.
Lighthouse Realty Holdings, LLC [e-mail]
Name E-mail Address
814 New Bridge Street,Suite D 814 New Bridge Street, Suite D
Current Mailing Address Current Street Address
Jacksonville NC 28540 Jacksonville NC 28540
City State Zip City State Zip

Telephone [phone] Fax Number
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 Finarctally 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.
Dominick Butch Mpnager,,
Type or print name Title or Authority
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I, 04 ZLSTiftt4E i—FE t fit)L7' „ a Notary Public of the County of Onslow
State of North Carolina, hereby certify that Dominick Butch appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
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Witness my hand and notarial seal,this day ofC�UCvT
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