NCC222646_FRO Submitted_20220803

cod Pitt County
Planning Department
Development Services Building
1717 W. 5th Street
rcwsteti Greenville, North Carolina 27834-1696
Telephone: [phone] James F. Rhodes, AICP
Fax: [phone] Director
Financial Responsibility / Ownership Form
Soil Erosion and Sedimentation Control Ordinance
No person may initiate any land -disturbing activity on one or more contiguous acres as
covered by the Act before this form and an acceptable erosion and sedimentation control plan
have been completed and approved by the Pitt County Planning Department. (Please type or
print and, if question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Kings Mill Subdivision
2. Location of land -disturbing activity: County Pitt
City or Township Ayden and Highway/Street Thad Little Road and
Weyerhaeuser Road
3. Approximate date land -disturbing activity will be commenced: 8/01/2022
4. Purpose of development (residential, commercial, industrial, etc.): Residential
5. Approximate acreage of land to be disturbed or uncovered: 12 Acres
6. Has an erosion and sedimentation control plan been filed? Yes X No
7. Person to contact should sedimentation control issues arise during land -disturbing activity:
Name Ken Malpass Telephone [phone]
8. Landowner(s) of Record (Use blank page to list additional owners):
Kenneth H. Smith
Name(s) Name(s)
1588 NC Hwy. 102 East
Current mailing address Street address
Ayden NC 28513
City State Zip City State Zip
9. Recorded in Deed Book No. 2123 Page No. 003
Part B.
1. Person(s) or,firm(s) who are financially responsible for this land -disturbing activity (Use
the blank page to list additional persons or firms):
Kenneth H. Smith
Name of person(s) or Firm(s) Name(s)
1588 NC 102 East
Current mailing address Street Address
Ayden NC 28513
City State Zip City State Zip
[phone]
Telephone Telephone

2. (a) If the Financially Responsible Party is a Corporation, give name and street address of
the Registered Agent.
Name(s)
Current mailing address
City State Zip
Telephone
Street Address
City State Zip
Telephone
(b) If the Financially Responsible Party is a Partnership give the name and street address
of each General Partner (Use blank page to list additional partners):
Name(s)
Current mailing address
City State Zip
Telephone
Name(s)
Current mailing address
City State Zip
Telephone
The above information is true and correct to the best of my knowledge and belief and was
provided by me under oath. (This fonn must be signed by the financially responsible person if
an individual or his/her attorney- in -fact or if not an individual by an officer, director, partner, or
registered agent with authority to execute instruments for the financially responsible person). I
agree to provide corrected informat ri s ould there be any change in the information provided
herein.
Kepoth H. Smith Owner
y `'or rint na Title or Authority
6/01/2022
gnatu -e — Date
I, W i jli" C. rawly gs , a Notary Public of the County of Alff State
of North Carolina, hereby certify that kehn-L Hl 9, Sn,i
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 1 s`f day of �t nQ . 20 ,-�Z.
Notary
My commission expires d/ ? 2m
® NOTARY
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