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HomeMy WebLinkAboutNCC221647_FRO Submitted_20220428JOHNSTON 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 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. Project Name Steven's Chapel Road Subdivision Phase 2 Location of land -disturbing activity: County Johnston City or Township Smithfield Highway/Street Steven's Chapel Rd Latitude 35.474438' N Longitude-78.246533' W 3. Approximate date land -disturbing activity will commence: Spring 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.82 Acres 6. Amount of fee enclosed: $ 2,660 . 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 X No Enclosed X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Kevin Varnell E-mail Address kvarnell(a.stocksengineering.com Telephone 252-459-8196 Cell # 252-382-0012 Fax # _ 252-459-8197 9. Landowner(s) of Record (attach accompanied page to list additional owners): RRT Development LLC 919-302-4906 N/A Name Telephone Fax Number PO Box 190 5215 Hwy 70 Bus Current Mailing Address Current Street Address Clayton NC 27528 Clayton NC 27520 City State Zip City State Zip 10. Deed Book No. 05779 Page No. 0303 (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): RRT Development, LLC Name PO Box 190 Current Mailing Address Clayton NC 27528 City State Zip Telephone 919-302-4906 hank(a)carolinacomfortair.com E-mail Address 5215 Hwv 70 Bus Current Street Address Clayton NC 27520 City State Zip Fax Number N/A 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 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 be any change in the information provided herein. John H. Richard Owner Type or print name Title or Authority gigKature Date /Ill i 1J y l� �i11 C%+ a Notary Public of the County of �b a l State of North Carolina hereby certify that D6, rd tl �11e_ a ►QC/ appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. �1111111//* ��b2c�2 \\�Amc�and notarial seal, this day of 0 0. N ® Tq R y Notary ® PVIIC My commission expires SP� ®� e� CC 0, ��