NCC240474_FRO Submitted_20240227

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 Flowers NE Quad revision
2. Location of land-disturbing activity: City or Township Flowers Plantation
Highway/Street NC HWY 42 Latitude 35.655740 Longitude -78.342749
3. Approximate date land-disturbing activity will commence: Fall 2022
4. Purpose of development(residential,commercial, industrial, institutional,etc.): Residential/Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 26 Ac. (+2 for Basing
6. Amount of fee enclosed: $ 5.800.00 . 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).
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 Andrew Stocks E-mail Address astocks(@.stocksengineering.com
Telephone [phone] Cell# 252-450-5140 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Flowers Holding Company LLC [phone] 252.459.8197
Name Telephone Fax Number
4880 NC 42 East Same
Current Mailing Address Current Street Address
Clayton NC 27520
City State Zip City State Zip
10. Deed Book No. 01789 Page No. 0784
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):
Flowers Holding Company LLC rhowersafiuwcrsplantation.com
Name E-mail Address
4880 NC 42 East Same
Current Mailing Address Current Street Address
Clayton _ NC 27520
City State Zip City State Zip
Telephone [phone] Fax Number 252.459.8197

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.
ecca Flowers Owner _
Type r print name Title or Authority
� O!- o� -aea-{
Sig ture Date
12445oel , a Notary Public of the County of . o 4S7 ni
State of North Carolina, hereby certify that ReJoeC.42- FEZ e+-S appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him. ,tG
Witness my hand and notarial seal, this T day of �A"itc , 20 el-4/1
,o,,,"",eid rrrrrrr''l
oeR , • ,o
- Notary
Ir
�IAR •
N�'_ My commission expires 9/,---4�ao�7
,o G
Ug \
•--
�q

Additional Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Development Services LLC [phone] 252.459.8197
Name Telephone Fax Number
2627 Brekonridge Centre Dr. Same
Current Mailing Address Current Street Address
Monroe NC 28110
City State Zip City State Zip