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HomeMy WebLinkAboutNCC220844_FRO Submitted_20220222JOHSTON 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: Woodmont — EC Plan for Lots 25 — 34 2. Location of land -disturbing activity: County: Johnston City or Township: O'Neals Highway/Street: Dundalk Drive Latitude: 35.6928 Longitude: - 78.2891 3. Approximate date land -disturbing activity will commence: January 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.7 acres 6. Amount of fee enclosed: $ 1,000.00 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). Residential lot plans are $100 per lot. 7. Has an erosion and sediment control plan been filed? Yes No Enclosed: X 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name: Scott Lee E-mail Address: lauraC@scottleehomes.com Telephone: (919) 553-2085 Cell: (919) 369-1937 Fax: (919) 9. Landowner(s) of Record (attach accompanied page to list additional owners): William R. O'Neal V (919) 538 8716 Name Telephone Fax 5 Nicklaus Way 5 Nicklaus Way Current Mailing Address Current Street Address Zebulon NC 27597 Zebulon NC 27597 City State Zip City State Zip 10. Deed Book No.: 5772 Page No.: 609— 610 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): Scott Lee Homes, Inc. Name 104 State Avenue, Suite 103 Current Mailing Address Clayton NC 27520 City State Zip Telephone: (919) 553-2085 lauraL@scottleehomes.com E-mail Address 104 State Avenue, Suite 103 Current Street Address Clayton NC 27520 City State Zip Fax _(919) 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 E-mail Address Current Street Address State Zip City Telephone 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: Laura S. Lee Name of Registered Agent 104 State Avenue, Suite 103 Current Mailing Address Clayton NC 27520 City State Zip Telephone (919) 553 2085 laura(o)scottleehomes.com E-mail Address 104 State Avenue, Suite 103 Current Street Address Clayton NC 27520 City State Zip Fax Number (919) 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. P. Scott Lee President, Scott Lee Homes, Inc. Type �r wit name Title or Authority S ih nature Date (' kk j a Notary Public of the County of ��� State of North Carolina, hereby certify that D±; c , appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this q 5.6 Seamy . °°�Ao7q s®; LICf °e!//IAfle151�1°0" My commission expires. Letter of Consent for Land Disturbance bn4 In v2s�rr�r� `"'" hereby give permission to Scott Lee Homes, Inc. to disturb land at Woodmont, Lots 25 — 34 for the purposes of constructing homes and installing septic systems. Please contact me at (919) 538 8716 if you have any questions or need additional information. Na /--4 ?'0Z"2: Date