NCC232381_FRO Submitted_20230815

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mm Erosion and Sedimentation Control Application
1. Applicant(s): D2 DAIRIO, LLC
Address: 300 S. Stratford Rd. Ste D, Winston Salem, NC 27103
Phone Number: 3 34,- (,0/- ,7 sv 5-
Interest in property: Redevelopment
(Owner, developer, registered agent, manager, etc.)
2. ePlan Applicant Info: (Information of the person who wi//be uploading documents to eplan;
First Name: Peyton Last Name: Woody
Email Address: [e-mail]
3. Owner of Property: D2 DAIRIO, LLC
(If not the applicant)
Address: 300 S.Stratford Rd. Ste D,Winston Salem, NC 27103
Fax Number: 3 3 (PO 2- 2 5 q t: Email: T-5( //i '-2_e G,1 A,2,'o.LC li
4. Description of property:
a. Location of Property/Address: ioo Parkwood Dr.,Jacksonville, NC 28540
b. Onslow County Deed Book: 5939 Page Number: 315
c. Onslow County Map Book: 345F Page Number: 88
d. Total Acreage in Tract: 3.3
e. Acreage to be Disturbed: 3.35
5. Submit the following documentation to Planning and Permitting:
a. One original fully executed Financial Responsibility/Ownership Form. (Attachment A)
b. One copy of a completed checklist along with all required information and documentation.
(Attachment B)
c. Check made out to the CITY OF JACKSONVILLE for the total amount due.
($225 for first acre plus $125 for every additional acre or portion thereof based on the
total disturbed acreage in the tract.)
d. Upload to eplan - Erosion control plan(s) along with all related details, calculations, and
documents as required on the checklist.
,- Sri - /—,Z 3
nature of Property ner or A..lic.-t Date

(A7 ACHMENTAJ
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 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 Environment and Natural Resources. (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: Dairi-0 Jacksonville
2. Location of land-disturbing activity: Onslow County City or Township: City of Jacksonville
Highway/Street: 100 Parkwood Dr Latitude: 34°778130 Longitude: 77° 389920
3. Approximate date land-disturbing activity will commence: July lst,2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.35
6. Amount of fee enclosed: $ 600
The application fee of$225.00 for the first acre plus$125 for every additional acre(rounded up to the
next acre)is assessed without a ceiling amount. (Example: 6.4-acre application fee is$975).
7. Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
4
Name: e f r S E-mail Address: 84 ,Q r bi/i.)0(e .S, 4/1'1
Telephone#: ,�j�(,� 6,0 2S-/1 Cell #: 63 272Prrogq, Fax #: 336•_/02-"_.2_S-
9. 360 So 5/, a, 5-S Le
Current MailingAddress �� l(� Adis � '
Currentad-
Street Address
�7f 3 /Aril 5.6.- di ?34
/ City State Zip City State Zip
10. Deed Book: 5939 Page Number: 315 (Provide a copy of the most current deed)
Part B.
1. 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):
D2 DAIRIO, LLC
Name E-mail Address
300 S. Stratford Rd. Ste D 300 S. Stratford Rd. Ste D
Current Mailing Address Current Street Address
Winston Salem NC 27103 Winston Salem NC 27103
City State Zip City State Zip
Telephone#: 34-102-2y'"j5~Cell #:iO3'-242. V 4. Fax#: 3‘•—GAL

•
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #: Cell #: Fax #:
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone #: Cell #: Fax #:
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.
Typ or print n�fm / Title or Authority
6///
Sig re Date
I. u n1n . n ,a Notary Public of the County of rpt59,
State of North Carolina, hereby certify that J--eteci Dean Specs II S 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 I S day of , 20 a 3
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AUTUMN L. LEpyIN Notary
NOTARY PUe.IC
Forsyth County; North Carolina My commission expires 14 P. 5 o '1
My Commission Expires Jun 5 2024