NCC223000_FRO Submitted_20220825

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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.
1. Project Name Arlington Trace Apartments
2.
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4
5
6
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9
E
Location of land -disturbing activity: County Pltt
Highway/Street Dickinson Ave. Latitude 35.592506
City or Township Greenville
Longitude-77.403249
Approximate date land -disturbing activity will commence: May 1, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.40 acres
Amount of fee enclosed: $ 1,140.00 . The application fee of $100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Scott T. Anderson, P.E. E-mail Address scott(@arkconsultinggroup.com
Telephone [phone] Cell # 252-258-0734 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Kate Vincent Kittrell
Name
Telephone
2771 Dickinson Ave. Ext. 2771 Dickinson Ave. Ext.
Current Mailing Address Current Street Address
Fax Number
Greenville NC 27834 Greenville NC 27834
City State Zip City State Zip
10. Deed Book No. 147 Page No. 820 Provide a copy of the most current deed.
Part B.
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):
Arlington Trace, LLC
Name
PO Box 566
Current Mailing Address
[e-mail]
E-mail Address
631 Dickinson Avenue
Current Street Address
Greenville NC 27835 Greenville NC 27835
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 by any change in the information provided herein.
Type or print name
Signature
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L. Havvis
Title or Authority
3•/d•Z._
Date
a Notary Public of the County of
State of North Carolina, hereby certify that T. /LAA � kS 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 10
`• Jennifer L Harris
NOTARY PUBLIC
My Commission
Seal Pitt County, NC
Expires AUGUST 27, 2025
_day of lk&, e'f'` , 20Q"'J' 2
o`. 0-iQ-A
Notary '
My commission expires zA", 4 Zi 2025