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HomeMy WebLinkAboutNCC240243_FRO Submitted_20240129 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 Carson's Landing Lots 1-17 2. Location of land-disturbing activity: City or Township Pleasant Grove Township Highway/Street Braxton Court Latitude 35.52883 Longitude -78.59893 3. Approximate date land-disturbing activity will commence: December 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11 .83 6. Amount of fee enclosed: $ 1 ,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: Brian Herring brianherring@greatsouthernhomes.com Name E-mail Address Telephone Cell# 919-650-8224 Fax# 9, Landowner(s)of Record (attach accompanied page to list additional owners): Great Southern Homes, Inc. 803-699-4734 Name Telephone Fax Number 90 N. Royal Tower Drive 90 N. Royal Tower Drive Current Mailing Address Current Street Address Irmo SC 29063 Irmo SC 29063 City State Zip City State Zip 10, Deed Book No, See Page No.Attachment 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): Great Southern Homes, Inc. brianherring@greatsouthernhomes.com Name E-mail Address 90 N. Royal Tower Drive 90 N. Royal Tower Drive Current Mailing Address Current Street Address Irmo SC 29063 Irmo SC 29063 City State Zip City State Zip Telephone 803-699-4734 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: Thomas Brian Herring brianherring@greatsouthernhomes.com Name E-mail Address 933 Old Knight Road 933 Old Knight Road Current Mailing Address Current Street Address Knightdale NC 27- Knightdale NC 27545 City State Zip City State Zip Telephone 919-650-8224 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. comas Bri :n Herring Registered Agent Typ r print a e I Title or Authority 1k-- a7 - ada3 in Date I, 6.(g1 Illce.c:i4avl , a Notary Public of the County of 7(ThOifzin { State of North Carolina, hereby certify that Thomas Brian Herring 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 7 day of ldVli V427. , 20 3 .` 0-0 %., \<<> / ":-• Notary !? 0TAF 96� )- = My commission expires 7 - a t - 4 PuBL\G