NCC215871_FRO Submitted_20211021

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.
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2.
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Project Name San Marino, Phase 4
Location of land -disturbing activity: City or Township Welders
Highway/Street San Perlro Dr. Latitude 35.652 Longitude.
Approximate date land -disturbing activity will commence: July 2021
-78.375
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.61
Amount of fee enclosed: $ 4,550.00 . 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).
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 Pablo Reiter E-mail [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton - Terramor, LLC 919-422-1166
Name Telephone Fax Number
7208 Falls of Neuse Road, Suite 201 7208 Falls of Neuse Road, Suite 201
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
10. Deed Book No. 5969 Page No.754-758
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):
D.R. Horton - Terramor, LLC [e-mail]
Name
E-mail Address
7208 Falls of Neuse Road, Suite 201 same as mailing
Current Mailing Address Current Street Address
Raleigh NC 27615 same as mailing
City State Zip
Telephone [phone]
City State Zip
Fax Number

Additional Insured - final lot will be purchased on Dec 15th.
42 East, LLC
8310 Bandford Way
Raleigh, NC 27615
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 State
Telephone,
E-mail Address
Current Street Address
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:
D.R. Horton - Terramor, LLC
Name of Registered Agent
7208 Falls of Neuse Road, Suite 201
Current Mailing Address
Raleigh
City
NC 27615
[e-mail]
E-mail Address
same as mailing
Current Street Address
same as mailing
State Zip City
Telephone [phone]
Fax Number
State Zip
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.
Pablo Reiter
Type or print name
Signature
Division President
Title or Authority
/, /o %ate I
Date
I, e� r i �. v1 �. �� - �� r c.- a Notary Public of the County of
State of North Carolina, hereby certify that �� >5 i_/ 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 2 6 -'day of �w� Sz 20
Adrienne Mabry
NOTARY PUBUC
pton County, NO
My Commission Expires January 22, 2022
Notary
My commission expires Z