NCC216103_FRO Submitted_20211104

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.
I . Project Name_ Osprey Landing
2. Location of land -disturbing activity: County Brunswick City or Township Southport
Highway/Street NIA Latitude 33056'16.8"N Longitude 7802'9.6"W
3. Approximate date land -disturbing activity will commence: March 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 72 ac
6. Amount of fee enclosed: $ 4680 . The application fee of $65.00 per acre (rounded up to the next
acre) is assessed without a ceiling amount. (Example: 9 acres total is $585).
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 Landon Weaver E-mail Address [e-mail]
Telephone [phone] Cell Fax
9_ Landowner(s) of Record (attach accompanied page to list additional owners):
Vanguard Farms Inc.
Name
200 E Arlington Blvd Ste R
Current Mailing Address
Greenville NC 27858
City State Zip
10. Deed Book No. 3499 Page No. 1040 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):
Bill Clark Homes of Wilmington, LLC 910 350-1744 910 350-1339
Name Telephone Fax Number
200 E. Arlington Blvd Ste A
Current Mailing Address Current Street Address
Greenville NC 27858
City State Zip City State Zip

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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City State Zip
Telephone.
E-mail Address
Current Street Address
City State Zip
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.
Lance L. Clark
Type or print name
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Manager
Title or Authority
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Date
�. u ►mot i� • a Notary Public of the County of iTLIct
State of North Carolina, hereby certify that 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 ` % ' fG ,L , 20.� 1
Seal
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Notary
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