NCC215563_FRO Submitted_20211007

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project NameWilson's Walk
2. Location of land -disturbing activity: City or TownshipWllson Mills
Highway/Street Latitude Longitude
Cole Road 35.5882145-78.42222288
3. Approximate date land -disturbing activity will commence:10/15/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):62
6. Amount of fee enclosed: $already paid 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 Fv] No ❑ Enclosed_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Raymond Rinker
E-mail [e-mail]
Telephone[phone] cell # 919-229-3238 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Starlight Homes North Carolina LLC
Name
Telephone Fax Number
5711 Six Forks Road Ste 300
5711 Six Forks Road ste 300
Current Mailing Address
Current Street Address
Raleigh NC 27609
Raleigh NC 27609
City State Zip
City State Zip
10. Deed Book No.5127 Page No.590
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):
Raymond Rinker
[e-mail]
Name
E-mail Address
5711 Six Forks Rd ste 300
5711 Six Forks Rd ste 300
Current Mailing Address
Current Street Address
Raleigh NC 27609
Raleigh NC 27609
City State Zip
City State Zip
Telephone[phone]
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
Telephon
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.
Raymond Rinker Vice President of Land Development
6�
Type or print na Title or Authority
t, _ 1015/2021
Signatu e Date
-----------------------------------------------------------------.------------------------------------------------------------------
I, , a Notary Mary Herold y Wake
Public of the Count of
State of North Carolina, hereby certify that Raymond Rinker 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 5 day of OCr �, 2021
MARY HILL HEROLD
NOTARY PUBLIC Notary
WAKE@QUNTY, N.C. ✓ �/ l
FCommission Expires 9-24-2026. My commission @xpireS" "'
�v