NCC223884_FRO Submitted_20221129

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 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 Peyton's Ridge, Section IX
2. Location of land -disturbing activity: County Onslow City or Township Swansboro
Highway/Street Aria Ln. Latitude 34.7293 Longitude-77.1985
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):. 48.5
6. Amount of fee enclosed: $ 4,900.00 . The application fee of $ioo.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? YesNo X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Elijah Morton
E-mail Address [e-mail]
Telephone [phone] _ Cell # — Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
South State Development, LLC [phone]
Name Telephone Fax Number
121 Garnet Lane
Current Mailing Address
Jacksonville NC
City State
10. Deed Book No. 5208
Part B.
121 Garnet Lane
Current Street Address
28540 Jacksonville NC 28540
Zip City State Zip
Page No 365 Provide a copy of the most current deed.
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.
South State Development, LLC [e-mail]
Name E-mail Address
121 Garnet Lane
Current Mailing Address
Jacksonville NC
City State
121 Garnet Lane
Current Street Address_
28540 Jacksonville NC 28540
Zip City State Zip

Telephone [phone]v 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
Telephone Fax Number
State Zip
(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
E-mail Address
_ Current Street Address
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 attomey-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.
Elijah Morton Member
Type p ' t name Title or Authority -
ign re Date
J 2SSi Ca La, Prv-e , a Notary Public of the County of-_�nSiBu)
State of North Carolina, hereby certify that i T t'1� nriv'n appeared
personally before me this day and being duly s m acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of , 20o
N*O
JESSSSICQJ IWRENCE i!
Notary ubliC My commission expires ID - a O - oik►
North Carolina
Onstow County