NCC216883_FRO Submitted_20211213

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 NORRIS ROAD TRACT - PHASE 1
2. Location of land -disturbing activity: City or Township CLAYTON
Highway/Street NORRIS ROAD Latitude 35.573182 Longitude -78.475809
3. Approximate date land -disturbing activity will commence: WINTER 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 59.54 AC.
6. Amount of fee enclosed: $ ALL PHASES PAID . 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).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
DENNIS PEACOCK E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
GRAY WOLF DEVELOPMENTS, LLC
Name Telephone Fax Number
10920 CLEVELAND ROAD
Current Mailing Address Current Street Address
GARNER NC 27577
City State Zip City State Zip
10. Deed Book No. 00561 Page No. 0113
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):
GRAY WOLF DEVELOPMENT, LLC. [e-mail]
Name E-mail Address
10920 CLEVELAND ROAD, SUITE 100 10920 CLEVELAND ROAD, SUITE 100
Current Mailing Address Current Street Address
GARNER NC 27529 GARNER NC 27529
City State Zip City State Zip
919-934-7788
Telephone 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
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.
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Type or print name Title or Authority
Signature Date
1, Zrene_ 0 ar Q S a , a Notary Public of the County of - krzAon
State of North Carolina, hereby certify that --be t'5 c C appeared
personally before me this day and being duly sworn acknow dged that the above form was
executed by him.
Witness my hand and notarial seal, this day of l C , 20 a /
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Johnston
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