NCC221557_FRO Submitted_20220504

01�FC'EFJV
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM fi AfAR o 9 Z022
SEDIMENTATION POLLUTION CONTROL ACT 8Y_
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 NIA in the blank.)
Part A.
1. Project Name Wildwood Tract
2. Location of land -disturbing activity: County Brunswick City or Township Shallotte
Highway/Street Wildwood Street Latitude 33.96 Longitude -78.42
3. Approximate date land -disturbing activity will commence: Spring/Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Subdivision
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.8
6. Amount of fee enclosed: $ $700.00 . 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name WJ McLamb E-mail Address [e-mail]
Telephone [phone] Cell # Fax # NIA
a
Landowner(s) of Record (attach accompanied page to list additional owners):
WJ McLamb Enterprises Limited Partnership 910-520-2727
Name Telephone
551 Wagon Wheel Trail Same
Current Mailing Address
Calabash NC 28467
City
State zip
NIA
Fax Number
Current Street Address
Same
City State Zip
10. Deed Book No. 2140 13764 Page No. 911 l 80 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.
WJ McLamb Enterprises Limited Partnership [e-mail]
Dame E-mail Address
551 Wagon Wheel Trail Same
Current Mailing Address Current Street Address
Calabash NC 28467 Same
City State Zip City State Zip
Telephone [phone] ORIGINAL

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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.
WJ McLamb Owner
Type or print name
y
Title or Authority
SignaturV / Date
a Notary Public of the County of Brunswick
State of North Carolina, hereby certify that WJ McLamb appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness�,p,i�:''tarial seal, this day of , 200 TA
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