NCC233094_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 Biscuitville - Flowers Plantation - Clayton
2. Location of land-disturbing activity: City or Township Flowers Plantation / Clayton
Highway/Street NC Hwy 42 Latitude 35.648557 Longitude -78.393011
3. Approximate date land-disturbing activity will commence: September 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0.92
6. Amount of fee enclosed: $ 400 . The application fee of$400.00 per acre (rounded
up to the next acre) is assessed for the first 8 acres and an additional$125 per acre for each additional
acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Harrell Queen E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LI.G ?ip—J55 —a900
Name Telephone Fax Number
1�-t4 . u\vil,L.e
Current Mailing Addre�6 Current Street Address
Care enoro t JG 2=1`k( O
City State Zip City State Zip
10. Deed Book No. 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):
U 2 So , L L-c `&a `.e.nn i,��,� � u i-4-viL(e corn
Name E-mail Add rs�s
\Co- c cuwi f S-r
Current Mailing Addre Current Street Address
V�e-e bt NG 21410
City State Zip City State Zip
Telephone 3- _S53-3410 0 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 tithe information provided herein.
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Type or print n U Title or Authority
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Signature Date
I, P\ADY\i(& L. 1K11Aik-e. , a Notary Public of the County of 2Ol�l.l \. d
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged at the above form was
executed by him.
Witness myAstritl"afid►rtgtarial seal, this 5 day of ge eM..6c.r, 20 2.S
. WVIY `
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Notary
Seal
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�°UB L• , My commission expires 2G
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