NCC217132_FRO Submitted_20211228

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 Arbor Plantation Lots 1 - 52
2. Location of land -disturbing activity: City or Township Oneals Township
Highway/Street NC 96 Latitude 35.7098 Longitude -78.2907
3. Approximate date land -disturbing activity will commence: 09/16/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 30.9 acres
6. Amount of fee enclosed: $ 6,425.00 . 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).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Khadijah Hasan E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Gray Wolf Homes, LLC 919-934-7788
Name Telephone Fax Number
10920 Cleveland Rd, Ste 100 10920 Cleveland Rd, Ste 100
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
10. Deed Book No. 05771 Page No. 0816
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 Homes, LLC [e-mail]
Name E-mail Address
10920 Cleveland Rd, Ste 100 10920 Cleveland Rd, Ste 100
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
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
Telephone
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.
Dennis Peacock
Type or print name
Signature
Land Aquisition and Land Development Manager
Title or Authority
91 n Izi
Date
b ent '60r&so , a Notary Public of the County of Zc6 n
State of North Carolina, hereby certify that hxenn"5 P,oN PeQc,,,rJC appeared
personally before me this day and being duly sworn acknowt6dged that the above form was
executed by him.
Witness my hand and notarial seal, this day of S20,9/
1B�ARe
Notary Public 9 Notary
,Johnston
Seal County =
My Comm. Exp. My commission expires -O/- o2/o
20 05-01-2026CA
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