NCC232494_FRO Submitted_20230817

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DEPARTMENT OF PUBLIC UTILITIES
Post Office Box 2263
SMITHFIELD, NC 27577
[phone]
April 12, 2023
NCDEQ Water Quality Section
ATTN: Mr. Fayad
3800 Barrett Drive
Raleigh, NC 27609
RE: Project Name: Holt Lake Force Main Upgrade
Project ID:JOHNS-2023-029
County:Johnston
City: Four Oaks
Address: Multiple
River Basin: Neuse
Stream Classification: C;NSW
Submitted By: Kim Rineer, Johnston County Public Utilities
Date Received by LQS: March 6, 2023
Plan Type: New
Dear Mr. Fayad:
Thank you for your letter of approval with modifications for the Holt Lake Force Main Upgrade
project. The following modifications were applied:
1. Show location of rain gauge and permits/record box on-site. The box is usually located
at the entrance of the project. (GS 113A-57(3), 15A NCAC 04B .0113)
Response: The rain gauge and permits/record box location is now shown on the plans.
2. Please indicate total disturbed acreage on appropriate plan sheet(s). The noted
disturbed area must exactly match that which is reported on the Financial
Responsibility/Ownership (FR/O) Form. If proposed disturbed area differs from what
was reported on the submitted FR/O form, please revise FR/O form and submit with
new notarized "wet" signature. Land disturbed acreage noted on the FRO form is 2.16
acres and land disturbed acreage noted on the plan set is 2.27 acres. They should
match.
Response: The revised FRO provided matches the acreage noted on the plans.

3. This permit allows for a land-disturbance, as called for on the application plan, not to
exceed 2.16 acres. Exceeding the acreage will be a violation of this permit and would
require a vised plan and additional application fee. Any addition in impervious surface,
over that already noted on the approved plan, would also require a revised plan to
verify the appropriateness of the erosion control measures and the stormwater
retention measures. (NCGS 113A-54.1(b)). Land disturbed acreage noted on the FRO
form is 2.16 acres and land disturbed acreage noted on the plan set is 2.27 acres.They
should match.
Response: The revised FRO provided matches the acreage noted on the plans.
4. Provide two copies of the plan set(one full-size and one half-size), showing the
modifications required for approval. To facilitate DEMLR review, bubble, highlight, or
otherwise identify the changes to your resubmittal. Provide one copy of additional
items (such as design calculations). Provide a cover letter referencing the project name,
project ID, and purpose for submittal. (G.S. 113A-57(4))
Response: This package includes one full-size and one half-size plan set. The changes are
highlighted.
If you need additional information, please advise.
Sincerely,
udy Wells, PE
Civil Engineer
Johnston County Public Utilities

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 Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Holt Lake Force Main Upgrade
2. Location of land-disturbing activity: County Johnston City or Township Four Oaks
Linear Project 35,47698 -78.37658
Highway/Street Latitude(decimaldegrees) Long itUde(declmaidegrees)
3. Approximate date land-disturbing activity will commence:ASAP
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Utility Installation
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.81
6. Amount of fee enclosed: $0($300 PAID PREVIOUSLY). The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kim Rineer E-mail Address [e-mail]
Phone: Office# 919-989-5725 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carolina Packers, Inc 919-934-2181 N/A
Name Phone: Office# Mobile#
PO Drawer 1109 2999 S Brightleaf Blvd
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A
Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
,an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
Johnston County [e-mail]
Company Name E-mail Address
P.O. Box 1049 309 E. Market St.
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
Phone: Office# 919-989-5100 Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office# Mobile#
Name of Individual,to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). i agree to provide
corrected information should there be any change in the information provided herein.
Rick J Hester Manager
Type_or-pricit name Title or Authority
Signs ure Date
n(X _ add/ark) -J h , a Notary Public of the County of •, C�An 1
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State of North Carolina, hereby certify thatk CK I-1esf 7- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this ) D f`day of 2 "'1' ( , 20 `
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record: .
Broughton Properties, LLC 919-782-7373
Name Phone: Office# Mobile#
1106 Marlowe Rd. 3175 S. Brightleaf Blvd.
Current Mailing Address Current Street Address
Raleigh NC 27609 Smithfield NC 27577
City State Zip City State Zip
Deed Book No. 05542 Page No. 0142 Provide a copy of the most current deed.
Landowner 3 of Record:
Ruth M. Penny N/A N/A
Name Phone: Office# Mobile#
2004 Cayuga Pl. N/A
Current Mailing Address Current Street Address
Raleigh NC 27612 N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 4 of Record:
Nell M. Howell Revocable Trust N/A • N/A
Name Phone: Office# Mobile#
PO Box 528 N/A
Current Mailing Address Current Street Address
Smithfield NC 27577 N/A
City State Zip City State Zip
Deed Book No. 03334 Page No. 0883 Provide a copy of the most current deed.
Landowner 5 of Record:
County of Johnston 919-989-5100 N/A
Name Phone: Office# Mobile#
PO Box 1049 309 E. Market St.
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
Deed Book No. 00855 Page No. 0148 Provide a copy of the most current deed.