NCC242135_FRO Submitted_20240723

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 Laurer Ridge lots 3, 4, 5, 15
2 Location of land-disturbing activity City or Township Wendell,
103Sbcumpr 21 53 2B Bar Code Ct 302.08" E
Highway/Street Latitude Longitude 88. 16' 07" N
3 Approximate date land-disturbing activity will commence
7/17/24
residential
4. Purpose of development (residential, commercial, industrial, institutional, etc )
0.5 acres
5 Total acreage disturbed or uncovered (including off-site borrow and waste areas)
6 Amount of fee enclosed S The application fee of S380 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 S100 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 Todd Eshenbaugh E-mail Address [e-mail]
Telephone [phone] Cell # 919-295-3416 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Blue Willow Homes LLC 919-295-3416
Name Telephone Fax Number
5 Wilsford Ct 5 Wilsford Ct
Current Mailing Address Current Street Address
Hillsborough NC 27278 Hillsborough NC 27278
City State Zip City State Zip
10. Deed Book No 6639 Page No, 405
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)
Blue Willow Homes [e-mail]
Name E-mail Address
5 Wilsford Ct 5 Wilsford Ct
Current Mailing Address Current Street Address
Hillsborough NC 27278 Hillsborough NC 27278
City State Zip City State Zip
Telephone [phone] Fax Number

.111111111111111.1"..----
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
Todd Eshenbaugh President
Type or print name Title or Authority
1
Signature Date
1 , 340\ier
a Notary Public of the County of lJUVrt
State of North Carolina, hereby certify that ( 4='<fAappeared
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 day of , 20 ik
JANET WEST
NOTARY PUBLIC Notary
Seal y WAKE COUNTY, NC
h1 COnrn ss on Expires 5-22-2026
My co missi n expires Dt