NCC222690_FRO Submitted_20220816

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Y
SEDIMENTATION POLLUTION CONTROL ACT MAY 162022
It
No person may initiate any land -disturbing activity on one or more acres as covered by the Aftb rye this form
and an acceptable erosion and sedimentation control plan have been completed and approved by th-e`ta-nd,-
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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1, Project Name PILCHERS BRANCH BORROW PIT MODIFICATION
2. Location of land -disturbing activity: County Onslow City or Township Folkstone
Highway/Street Pilchers Branch Drive Latitude(decimaidegrees) 34.5500 Longitude(decimaidegrees)_-77.495
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.7 previous + 1.2 =
4.90 ac total
6. Amount of fee enclosed: $ 2x$100=$200.00 The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8A 0-acre application fee
is $900). Checks should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ® Enclosed M No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Will Alexander E-mail Address getrightenterprisesllcagmail. corn
Phone: Office # 910 264 6782 Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
Get Right Investments II, LLC _ _910-264-6782
Name Phone: Office #
103 Ashley King Road
Current Mailing Address
Holly Ridge NC 28445
City State Zip
same
Current Street Address
Mobile #
same
City State Zip
10. Deed Book No. 5270 Page No. 402 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Get Right Investments II, LLC 910-264-6782
Name Phone: Office # Mobile #
103 Ashley King Road same
Current Mailing Address Current Street Address
Holly Ride NC 28445 same
City State Zip City State Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Curr Street
State Zip City
Mobile #
Name of Individual to Contact (if Wegistered Agent is a c,6mpany)
State Zip
(b) If the Financially Respo sible Party is not a rest ent of North Carolina, give name and street address
of the designated North rolina agent who is regisltered on the NC Secretary of State business registry:
Name of Registere�'Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
�i
BY_

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As, If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Type or print name Title or Authority
22~2-
Signature Date
I, kk , a Notary Public of the County of NAW 6mayey
State of North Carolina, hereby certify that WAk AVE 1,pa\AA _appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this Z$ day of YCk1 , 2090,
Seel _ NOTARY
PUBLIC z
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Notary
My commission expires__