NCC230182_FRO Submitted_20230203

JOHNSTON COUNTY 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
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 /VIA in the blank.)
Part A,
1. Project Name Pine Tree Knolls 22-26
2. Location of land -disturbing activity: City or Township Micro
Highwav/Street Red Rive Drive Latitude 35.5503 Longitude-78.171 S
3. Approximate date land -disturbing activity will commence: November, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.20
6. Amount of fee enclosed: $ 500 . 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 ❑ No ❑ Enclosed__
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Stanley E-mail [e-mail]
Telephone [phone] Cell 9 910-424-0455 Fax # nla
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Westan Construction
910-424-0455 nla
Name
Telephone Fax Number
PO Box 25640
6506 Dental Lane, Suite 201
Current Mailing Address
Current Street Address
Fayetteville NC
28814
Fayetteville NC 28314
City State
Zip
City State Zip
10. Deed Book No. 6361
Page No.
817
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):
Westan Construction
[e-mail]
Name
E-mail Address
PO Box 25640
6506 Dental Lane, Suite 201
Current Mailing Address
Current Street Address
Fayetteville NC
28344
Fayetteville NC 28314
City State
Zip
City State Zip
Telephone [phone]
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 of Registered Agent 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.
Robert Stanley
Type or pri t name
Signature
President
Title or Authority
/7_ z 3.
Date
I, J�K 1A4_e._ Z l r , a Notary Public of the County ofZ�4
�l
State of North Carolina, hereby certify that ` 'j �� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my L�gpdqd notarial seal, this day of � ' , 20
NO%
Notary Public
Harnett County Notary
My CorSebtion Expires
2l �= My commission expires__ _,
1/1irrriWO