NCC250022_FRO Submitted_20250122

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 the 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.)
P1.art AProject Name Danford Road Offsite Forcemain
Brunswick BOLIVIA
2. Location of land-disturbing activity: County City or Township
Highway/Street Danford Road Latitude 34°04'01.93"N Longitude 78°07'32.11"W
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3. Approximate date land-disturbing activity will commence:September 2025
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Utility (Forcemain)
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5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.27
6. Amount of fee enclosed: $ 300 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac= $900.00). €i
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 STEVE SHUTTLEWORTH E-mail Address [e-mail]
Telephone [phone] Cell# 719-499-1373 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
North Carolina Department of Transportation(NCDOT) [phone]
Name Telephone Fax Number
300 Division Drive
Current Mailing Address Current Street Address
Wilmington NC 28401
City State Zip City State Zip
10. Deed Book No.n/a Page No.n/a 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 may be listed as the financially responsible party.
J&S LAND DEVELOPEMENT, LLC [e-mail]
Name E-mail Address
8620 RIVER ROAD
Current Mailing Address Current Street Address
WILMINGTON NC 28412
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 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.
STEVE SH?WORTH Member
Type .r prij� e Title or Authority
4
Signature Date
kiate_e- I , a Notary Public of the County of i((iW ci'' tiv
State of North Carolina, hereby certify that 61 hu /C -hth4 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 I Prfilday of Ochibed ,(, 20
TERRI D HARRELL J...tAAL NOTARY PUBLIC
NEW HANOVER County
North Carolina Notary
My Com Expires JULY 8,202F / g a `�My commission expires''
/ 4

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: F
WILLIAMSON & HARDY LLC
Name Phone: Office# Mobile#
2618 NEW VILLAGE WAY
Current Mailing Address Current Street Address
WILMINGTON, NC 28405
City State Zip City State Zip
Deed Book No.01948 Page No.0983 Provide a copy of the most current deed.
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(4F
Landowner 3 of Record:
MCKEITHAN EVELYN L
Name Phone: Office# Mobile#
1003 OLD LYNCHBURG RD
Current Mailing Address Current Street Address
CHARLOTTESVLE, VA 22903-7810
City State Zip City State Zip
Deed Book No.232 Page No.794 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.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#