NCC217185_FRO Submitted_20220107

JOHNSTON COUNTY 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
Johnston County Department of Public Utilities. (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 HOLLY TREE GROVE
2. Location of land -disturbing activity: City or Township TOWN OF BENSON
Highway/Street N JOHNSON ST Latitude 35.386356 Longitude-78.538369
3. Approximate date land -disturbing activity will commence: FALL 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 6.0
6. Amount of fee enclosed: $ 2,284 . The application fee of $380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $125 per acre for each
additional acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name CATHERINE F. CONNORS E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners).
HOLLY TREE GROVE NC LLC [phone]
Name Telephone Fax Number
106 MUIR WOODS DRIVE 106 MUIR WOODS DRIVE
Current Mailing Address
CARY, NC 27513
City State
10. Deed Book No. 4862
Part B.
Zip
Page No.
Current Street Address
CARY, NC 27513
City
138
State
Zip
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):
HOLLY TREE GROVE NC LLC CATHY.CONNORS SOLSTICEPARTNERS.NET
Name E-mail Address
106 MUIR WOODS DRIVE
Current Mailing Address
CARY, NC 27513
City State Zip
Telephone [phone]
106 MUIR WOODS DRIVE
Current Street Address
CARY. NC 27513
City State Zip
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:
N/A
Name
N/A
Current Mailing Address
N/A
City State
Telephone
N/A
N/A
E-mail Address
N/A
Current Street Address
U /A
Zip City State Zip
Fax Number N/A
(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:
NIA
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone. N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
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.
CATHERINE F. CONNORS
Type or print name
Signature
1, Lit X" rr P1, S4
MANAGING MEMBER
Title or Authority
3 - a
Date
a Notary Public of the County of �✓���°
State of North Carolina, hereby certify that 00 ap^^u F• 60M h-ais 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 day of , 20-L t
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Notary
6 0�4' __ My commission expires
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