NCC233095_FRO Submitted_20231016

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 Lots 1 ,5,6,13,14,15,18 Talton Pointe
2. Location of land-disturbing activity: City or Township 0'neals Township
Highway/StreetNoramac Court Latitude35°40'20.6"N Longitude78°15'07.9"W
3. Approximate date land-disturbing activity will commence:TB
D
4. Purpose of development(residential, commercial, industrial, institutional, etc.):residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):7.26
6. Amount of fee enclosed: $700.00 . 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 ✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Scott Weingartner E-mail Address [e-mail]
Telephone [phone] Cell# 9 1 9-669-0399 Fax# NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Southview Homes, LLC 919-422-9707
Name Telephone Fax Number
PO Box 9 200 Hwy 70E
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
10. Deed Book No.See attached Exhibit A Page No.
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):
Southview Homes, LLC [e-mail]
Name E-mail Address
PO Box 9 200 Hwy 70E
Current Mailing Address Current Street Address
Garner NC 27529 Garner North Carolina 27529
City State Zip City State Zip
Telephone [phone] Fax Number NA

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.
Adam Kingsley Co-owner
Type or •r' It name Title or Authority
Sig . . a Date
I, CIenn , a Notary Public of the County of 01wm.L -
State of North Carolina, hereby certify that i4d�=1,1 r-iek ( 3 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 jL-, day of )h� , 20 2077"" 4\'
▪ Notary Public ?a
Notary
/4ton
• My Comm.ounty Exp, My commission expires 6`// 7/ "2'4 Y
Q. 09-17-2024 Tr
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EXHIBIT A
Southview Homes, LLC
Talton Pointe Lots
Book of Deeds
Lot# Street Number Street Name Deed Book# Page#
1 25 Noramac Court 06307 0130
5 141 Noramac Court 06303 0959
6 163 Noramac Court 06303 0959
13 258 Noramac Court 06307 0130
14 252 Noramac Court 06307 0130
15 240 Noramac Court 06307 0130
18 186 Noramac Court 06307 0130