NCC223614_FRO Submitted (2)_20221109

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may-nitiate 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 NIA in the blank.)
Part A.
1. Project Name Old Smith Downes
2. Location of land -disturbing activity: City or Township Selma, Johnston County
Highway/StreetOld Smith Road Latitude35,683028 Longitude-78.321279
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institut,-onal, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site Morrow and waste areas): 3.52
6. Amount of fee enclosed: $ 1,520 . 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.
7. Has an erosion and sediment control plan been filed? Yes�� No--[]_ Enclosed��
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John Downes E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Askeaton Realty, LLC 210-257-9503
Name
3306 Edge View
Current !Nailing Address
San Antonio TX 782%
Telephone
Current Street Address
Fax Number
City state Zip City State Zip
10. Deed Book No.6255 Page No.103
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):
Askeaton Realty, LLC [e-mail]
Name E-mail Address
3306 Edge View
Current Mailing Address Current Street Address
San Antonio TX rs2�
City State Zip
Telephone [phone]
City State Zip
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:
Shawn Murphy [e-mail]
Name E-mail Address
150 East Walkefwoods Lane
Current Mailing Address
Clayton NC
City State Zip
Telephone [phone]
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:
Name of Registered Agent
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
City State Zip
Telephone 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 attomey-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.
Shawn Murphy
Type or print name
Ui—Rifure
Registered Agent
Title or Authority
Date
I,SOMC1 rL'� L f') e - a Notary Public of the County of
State of North Carolina, hereby certify that `f\CkW n On i.b Tthe _appeared
personally before me this day and being duly swom acknowledged that above form was
executed by him.
Witness my hand and notarial seal, this 11 44" day o 1A 's 20'Z
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