NCC220844_FRO Submitted_20220222

JOHSTON 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: [e-mail]
Telephone: [phone] Cell: [phone] Fax: (919)
9. Landowner(s) of Record (attach accompanied page to list additional owners):
William R. O'Neal V [phone]
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: [phone]
[e-mail]
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 [phone]
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
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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
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My commission expires.

Letter of Consent for Land Disturbance
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`"'" 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 [phone] if you have any questions or need additional information.
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