NCC231005_FRO Submitted_20230414

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 Barefoot Ridge
2. Location of land-disturbing activity: City or Township Archer Lodge WllderS
Highway/Street South Murphrey Road Latitude 35.68326 Longitude-78.37566
66
3. Approximate date land-disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.46
6. Amount of fee enclosed: $ 1 ,1'4'0.00 . 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). Individual residential lots plans are $100 per lot.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed If _
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Randy Summerlin E-mail Address [e-mail]
Telephone Cell# 919-422-1707 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Barsum Investments, LLC
Name Telephone Fax Number
640 South Murphrey Road 640 South Murphrey Road
Current Mailing Address Current Street Address
Archer Lodge NC 27527 Archer Lodge NC 27527
City State Zip City State Zip
10. Deed Book No. 6229 Page No.421-423
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):
Barsum Investments, LLC [e-mail]
Name E-mail Address
640 South Murphrey Road 640 South Murphrey Road
Current Mailing Address Current Street Address
Archer Lodge NC 27527 Archer Lodge NC 27527
City State Zip City State ;- Zip
919-422-1707
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip 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 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.
Randy Summerlin Managing Member
:7. rint ame ► Title or Authority
3-29-2023
nat re Date
Steven S. Sanderson , a Notary Public of the County of Wake
State of North Carolina, hereby certify that Randy Summerlin 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 29 day of M ,r ch 20 2023
��O1l
f Est. v�en S. Sanderson ' q
r••w•:€ry Public Notary
•,Nuiks unty, C 3 en
My Cc mmission Expires l�• My commission expires 11-3-2027