NCC223346_FRO Submitted_20221003

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
2.
3.
4.
5.
6.
7.
8.
Project Name Norris Tract - Phase 2
Location of land -disturbing activity: City or Township Clayton
Highway/Street Norris Road Latitude 35.573182 Longitude-78.475809
Approximate date land -disturbing activity will commence: 09/01/2022
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas):'05
Amount of fee enclosed: $$150 transfer fee 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.
Has an erosion and sediment control plan been filed? Yes ❑✓ No ❑ Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Trey Eades E-mail Address [e-mail]
Telephone [phone] cell # 9198192360 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DR Horton Inc
9194972163
Name
Telephone Fax Number
7208 Falls of Neuse Road Suite 201
Current Mailing Address
Current Street Address
Raleigh NC 27615
City State Zip
City State Zip
10. Deed Book No.6316 Page No.204-208
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):
DR Horton Inc
tmdavisl @drhorton.com
Name
E-mail Address
7208 Falls of Neuse Road Suite 201
Current Mailing Address
Current Street Address
Raleigh NC 27615
City State Zip
City State Zip
9194972163
Telephone
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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
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.
fr .
T p or print Mme Title or Authority
Signature Date
(C-n mu & 'kkn o' , a Notary Public of the County of _Wake -
State of North Carolina, hereby certify that _ (O.G�U Y 1 Owt� 5 appeared
personally before me this day and being duly sworA acknowledged that the above form was
executed by him. nn
Witness my hand and notarial seal, this Z day of l �� �:s� 20. c2\
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