NCC232227_FRO Submitted_20230727

Check if this project is ARPA--funded fl
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Fieldview Village Phase 2 Lots 10, 16-32, 50-51
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Johnston City or Township Four Oaks
Pecan Valley Way 35.45403 -78.43566
Highway/Street LatltUde(decimai degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 7/6/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6'44
6. Amount of fee enclosed: $ NA . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes El Enclosed El No El
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Brian Herring E-mail Address [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Herring Realty, LLC 919-650-8224
Name Phone: Office# Mobile#
1070 N. Lakeside Drive 1070 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
10. Deed Book No. 6486 Page No. 76-78 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Herring Realty, LLC dba Herring Homes [e-mail]
Company Name E-mail Address
1070 N. Lakeside Drive 1070 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
Phone: Office# Mobile#[phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Thomas B. Herring [e-mail]
Name of Registered Agent E-mail Address
1070 N. Lakeside Drive 1070 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Herring Realty, LLC dba Herring Homes
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
T ►':s B. Herring Managing Member
T pe or'•rint nam= Title or Authority
— PP'S 6/6/23
Si. ature Date
Steven S. S nder,on a Notary Public of the County of Wake
State of North Carolina, hereby certify that Thomas B. Herring appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 6 day of J U n •23
Steven S. Sanderscr)
Notary Public
Wake County. iN Notary
M Commission Ex Tres U - '27 11/3/27
My commission expires

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Herring Realty, LLC 919-650-8224
Name Phone: Office# Mobile#
1070 N. Lakeside Drive 1070 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
Deed Book No. 6477 Page No.414-416 Provide a copy of the most current deed.
Landowner 3 of Record:
James E. Allen, LLC 919-604-7120
Name Phone: Office# Mobile#
5000 Falls of Neuse Road, Suite 100 5000 Falls of Neuse Road, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Deed Book No. 6477 Page No. 397-399 Provide a copy of the most current deed.
Landowner 4 of Record:
Andwade, LLC 919-250-8428
Name Phone: Office# Mobile#
8480 Bryan Road 8480 Bryan Road
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
Deed Book No. 6477 Page No. 662-664 Provide a copy of the most current deed.
Landowner 5 of Record:
Frederic E. Privette 919-427-5536
Name Phone: Office# Mobile#
PO Box 1250 2509 Holiday Road
Current Mailing Address Current Street Address
Knightdale NC 27545 Zebulon NC 27597
City State Zip City State Zip
Deed Book No. 6479 Page No. 867-869 Provide a copy of the most current deed.