NCC220203_FRO Submitted_20220111

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.)
Project Name Sunshine Meadows Phase 2 Section 4
Location of land -disturbing activity: City or Township Boon Hill
Highway/Street Dry Branch Drive Latitude 35.52143 Longitude-18.13167
Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.79
6. Amount of fee enclosed: $ 760.00 ___. 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). individual residential lots plans are $100 per lot.
7. Has an erosion and sediment control plan been filed? Yes LL No ❑ Enclosed _
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Barry McCamant
E-mail [e-mail]
Telephone
— Cell # 910-495-4673 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Orion Land Holding, LLC 910-495-4673
Name
Telephone flax Number
936 Kennesaw Drive
936 Kennesaw Drive
Current Mailing Address
Current Street Address
Fayetteville NC
28314 Fayetteville NC 28314
City State
Zip City State Lip
10. Deed Book No. 5170
Page No. 805-30 7---
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):
Orion Land Holding, LLC brymct@y,ahoo.com
Name
E-mail Address
936 Kennesaw Drive
936 Kennesaw Drive
Current Mailing Address
Current Street Address
Fayetteville NC
28314 Fayetteville NC 28314
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.
Barry McCamant Managing Member
Type print name i-itle or A(Ahor ty
/'/1"� / 27
Signature Date
C ' �G!H a Notary Public of the County of urn'"Cr
State of North Carolina, hereby certify that I ( iM G Ci-l`Gn4-` 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 day of i /Oyen7 1&- 20 Z
SEPRINA NEALY
Notary Public otar
�yerland Co., North Carolina Y
My ommission Expires July 12, 2026
My commission expires 71 ?az