NCC232326_FRO Submitted_20230808

JOHNSTON COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
land-disturbing activity on one or more acres as covered by
the Pro before this
No person n may a initiate any dbye
form and an acceptable erosion and sedimentatione leaset type
have
and, if the question is not applicable
r
Johnston County Department of Public Utilities.
the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
Lot 12 Talton Pointe
1. Project Name ___.______ Township
______
NoramaC Court
2. Location of land-disturbing activity: City or Townsh5t��0�20.Q'neals 6"N 73°1 5'Q7.9„W
Latitude __ Longitude
3. Approximate date
Highway/Street - - _
land-disturbing activity will commence: TBD
residential
4. Purpose of development (residential, commercial, industrial, institutional, etc.): 3
5. Total acreage disturbed or uncovere
d including off-site borrow and waste areas): 1 .0
6. Amount of fee enclosed: $ 1 00.00 . The application fee of $380.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional
ia la$e 25$1 per
0 pea re for each
additional acre (rounded up to the next acre). Individual residentiallots
p
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 Hayden Marshburn E-mail Address [e-mail]
Telephone
[phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hayden Marshburn [phone]
Name Telephone Fax Number
8487 Central Drive
Current Mailing Address Current Street Address
Raleigh NC 27613
City State Zip City State Zip
10. Deed Book No. 06298 Page No. 0996
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):
Hayden Marshbum Custom Homes, LLC [e-mail]
Name E-mail Address
8487 Central Drive
Current Mailing Address Current Street Address
Raleigh NC 27613
City State Zip City State Zip
Telephone[phone] 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:
_ E-mail Address
Name
Current Mailing Address
Curren# Street Address
- -- - ZipCity State Zip
City State
Fax Number_
Telephone_(b) ___
Financially Responsible Party is a Partnership or other persoen engaging F in business
ly ss under
an
If the Fina Y
assumed name, attach a copy of d st Certificate
of the Registered Agent:
Party is a Corporation, give name an
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
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.
Hayden Marshburn Owner/ Manager
Type or print name Title or Authority
r
jSiJnkli
9na Date
tur e --__--_----�.--_
a Notary Public of the County of Lk )ct 4.EL
State of North Carolina, hereby certify that Nwvtgeit filc4- u .'` 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 l l day of LA (y , 20 )„,)7_ 7"; -
5
Morgan Grudzinski Se Notary
TARP PUBLIC ---' r ,
Wake County,NC Mycommission expires ,j
My Commission Expires September 23,2025 p