NCC217011_FRO Submitted_20220106

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 PINECREST SUBDIVISION
2. Location of land -disturbing activity: City or Township PINE LEVEL TOWNSHIP
Highway/Street PI NECREST RD Latitude 35.508727 Longitude -78.231235
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
380*10=3800
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27.05 AC 18*125=2250
6,050 $6,050
6. Amount of fee enclosed: $ 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
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name ADAM STUCKEY E-mail Address [e-mail]
Telephone [phone] cell # NA Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RICHARD D BRASWELL NA NA
Name Telephone Fax Number
PO BOX 2346
Current Mailing Address Current Street Address
SMITHFIELD NC 27577
City State Zip City State Zip
10. Deed Book No. 05889 Page No. 431-432
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):
SAS LAND DEVELOPMENT, LLC [e-mail]
Name E-mail Address
1388 RAINS CROSSROADS ROAD
Current Mailing Address Current Street Address
PRINCETON NC 27569
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
(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:
ADAM STUCKEY
Name of Registered Agent E-mail Address
1388 RAINS CROSSROADS RD
Current Mailing Address Current Street Address
PRINCETON NC 27569
City
State Zip
Telephone [phone]
City State Zip
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.
ADAM STUCKEY
Type r pri t name
Signature
MANAGER
Title or Authority
Date
1, f4o I 1 mvA I"ti ,rub , a Notary Public of the County of J ohnmJ l
State of North Carolina, hereby certify that Acko_r r1 appeared
personally before me this day and being duly sworn acknowledged at the above form was
executed by him.
Witness my hand and notarial seal, this ICE
Hoilat�ra�dyy Adams
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Jo1�i4 n CCouunnty
LMC*m mission Carolina 12-1I-21
day of 20 Zl
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My commission expires f ,2 —1 / _e20 a 1