NCC240835_FRO Submitted_20240322

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 Annandale Phase 4
2. Location of land-disturbing activity:: CityTownship
or Cleveland
Highway/Street Cornwallis Road Latitude 35.57234 Longitude -78.55958
(SR 1525)
3. Approximate date land-disturbing activity will commence: January 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 51.27
6. Amount of fee enclosed: $ 9,250.00 , The application fee of$400.00 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Doug Lawrie E-mail Address [e-mail]
Telephone [phone] Cell# 919-746-6048 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Philip & Kathleen Wood 919-337-3174
Name Telephone Fax Number
1633 Cornwallis Road 1633 Cornwallis Road
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
10. Deed Book No. 02661 Page No. 0834
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):
Wood Property Developments, LLC [e-mail]
Name E-mail Address
4112 Blue Ridge Road, Suite 210 4112 Blue Ridge Road, Suite 210
Current Mailing Address Current Street Address
Raleigh NC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone [phone] 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 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 copyof the Certificat
e of Assumed Name. If
the Financially Responsible
onsible
Party is a Corporation, give name and street address of the Registered Agent:
g g
Name of Registered Agent g g 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 myknowledge and belief and was g 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.
David Stallings Member/Mana
ger
Type or pr nt-na a -- Title or Authority
12/4/23
Sigfe Date
I, Konstantina Bakatsias , a Notary Public of the County of Wake
State of North Carolina, hereby certify that David Stallings appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness°,gnyl1' gtldhood notarial seal, this 4th day of December , 20 23
d
NOTARY ,u Notary
Pt.
`. ',CJ a My commission expires September 15th, 2025
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