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HomeMy WebLinkAboutNCC223372_FRO Submitted_20220930JOHNSTON 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 Norris Tract - Phase 1 2. Location of land -disturbing activity: City or Township Clayton Highway/StreetNorris Road Latitude35.573182 Longitude-78.475809 3. Approximate date land -disturbing activity will commence: 09/0 1 /2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.); residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas), 59.54 6. Amount of fee enclosed: $$150 transfer fee 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). Individual residential lots plans are $100 per lot. 7. Has an erosion and sediment control plan been filed? Yes R1 No ❑ Enclosed_ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Trey Eades Email Address HTEades@drhorton.com Telephone9194972163 cell # 9198192360 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): DR Horton Inc 9194972163 Name Telephone Fax Number 7208 Falls of Neuse Road Suite 201 Current Mailing Address Current Street Address Raleigh NC 27515 City State Zip City State Zip 10. Deed Book No.6316 Page No.204-208 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): DR Horton Inc tmdavis1 @drhorton.com Name E-mail Address 7208 Falls of Neuse Road Suite 201 Current Mailing Address Raleigh NC 27615 City State Zip Telephone 9194972163 Current Street Address 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: Name Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip 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 Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City Fax Number State Zip 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. Y Qc 'N�- i)Ov\S l� \ \J � s \b n N�Pi)f- ec�. j , T or print nAlne Title or Authority ? �)liZ 1 -?_0ZZ Signature Date ------------------------------------------------------------------------------------------------------------------------------------ I, l a in r t (� l,I I� C � � Y S , a Notary Public of the County of State of North Carolina, hereby certify that 1 ( 1 S appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. l Witness my hand and notarial seal, this day of I`ru S�1 , 20 ,•,`,,`, SAUIVp" F . •`•�• ...............'Q '% , S No ary hit PUB, \c' My commission expiresJC ,F 42 •.