NCC215782_FRO Submitted_20211018

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 NIA in the blank.)
Part A.
2
5
0
0
IC
Project NameTalton Pointe Subdivision (Formerly Atkinson Mill Subdivision)
Location of land -disturbing activity: City or Township O'Neals
Highway/Street Atkinson Mill Road Latitude 35.67190 Longitude-78.25270
Approximate date land -disturbing activity will commence: July 2021
Purpose of development (residential, commercial, industrial, institutional, etc_): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.0 acres
Amount of fee enclosed: $1,320.00. The application fee of $330.00 per acre (rounded up to the next acre)
is assessed for the first 10 acres and an additional $110 per acre for each additional acre (rounded up to the
next acre).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Morrison E-mail Address notefundertc-baol.com
Telephone N/A Cell # 919-210-0561 Fax # NIA
Landowner(s) of Record (attach accompanied page to list additional owners):
MHB Development, LLC 919-210-0561
Name Telephone
208 Forest Oaks Dr.
Current Mailing Address
Current Street Address
Archer Lode NC 27527
City State Zip City
10. Deed Book No.05051 Page No 325
Part B.
State
NIA
Fax Number
Zip
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):
MHB Development, LLC
Name
208 Forest Oaks Dr.
Current Mailing Address
Archer Lodge NC 27527
City State Zip
919-210-0561 N/A
Telephone Fax Number
Current Street Address
City State Zip

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
NIA
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
-
Type or pri name Titleor Authority
Signa f u r e Date
I, AO 4 A Q, a� a Notary Public of the County of 9,4,i?NE
State of North Carolina, hereby certify that N—r-145 1401mr-an! 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 / d
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