NCC216847_FRO Submitted_20211217

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.
1. Project Name BRASWELL ROAD EXTENSION
2 Location of land -disturbing activity: City or Township PINE LEVEL TOWNSHIP
Highway/Street' EEDIN RD Latitude 35.49234 Longitude-78.25986
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): STREET
17.2 AC 380*10=3800
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 125* 8=1000
4,800 $4,800
6 Amount of fee enclosed: $ The application fee of $380.00 per acre (rounaea
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).
7. 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 RICHARD BRASWELL Email Address [e-mail]
Telephone [phone] Cell # NA Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RICHARD D BRASWELL Revocable Trust 919-291-4853 NA
Name Telephone Fax Number
3241 US Hwy 70E STE 101
Current Mailing Address Current Street Address
SMITHFIELD NC 27577
City State Zip City State Zip
10. Deed Book No. 05662 Page No. 0960
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):
New Day Development Corporation [e-mail]
Name
3241 US 70E STE 101
Current Mailing Address
Smithfield NC 27577
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City
Fax Number
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:
Richard Braswell
Name of Registered Agent E-mail Address
3241 US 70E STE 101
Current Mailing Address Current Street Address
Smithfield NC 27577
City State Zip City State Zip
Telephone [phone] 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.
Richard Braswell President
Tyke or print e 11 Title or Authority
Signature Date
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I, B . 46•6 t)ryup-n , a Notary Public of the County of I)SIVO
State of North Carolina, hereby certify that �."0 �rc��t� t'. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
y _ day of tr7 20� Witness m hand and notarial seal, this ,
Notary
Seal
My commission expires