NCC220470_FRO Submitted_20220201

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 Everwood Phase ¢ Subdivision
2. Location of land -disturbing activity: City or Township 1E,1.E�11A7;Qtj To�/us�lP
Highway/Street Hwy 210 Latitude 35"30'28.59"N Longitude 78°31'31.61 "W
3. Approximate date land -disturbing activity will commence: Upon Receipt of Permit
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 32 acres
6. Amount of fee enclosed: $ 3,928.00 . The application fee of $275.00 per acre (rounded
up to the next acre) is assessed for the first 8 acres and an additional $72 per acre for each additional
acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes No 1:1Enclosed_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Harold G. Carroll, Jr. E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
M
Landowner(s) of Record (attach accompanied page to list additional owners):
Steel Bridge Crossing, L.L.C. [phone]
Name Telephone
63 Vernon Court 63 Vernon Court
Current Mailing Address
Willow Springs NC 27592
City State
10. Deed Book No. 05030
Part B.
Zip
Page No
[phone]
Fax Number
Current Street Address
Willow Springs NC 27592
City State Zip
0284
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity
comprehensive list of all responsible parties on an attached sheet):
Steel Bridge Crossing, L.L.C. stephanie@buildech,corn
Name E-mail Address
63 Vernon Court 63 Vernon Court
Current Mailing Address Current Street Address
Willow Springs NC 27592 Willow Springs NC 275,
City State Zip City State
Telephone [phone] Fax Number [phone]

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;
NIA NIA
Name E-mail Address
NIA N/A
Current Mailing Address Current Street Address
N/A N/A
city State Zip City state mm� Zip
Telephone N/A Fax Number NIA
(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
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone
N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State - — - Zip -
Fax Number NIA
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). l agree to provide
corrected information should there be any change in the information provided herein.
fl4 al d a. Lav I i,
Type or t name �.
S' ature
Title: or Authority
y
Date
1,N.I.�, a Notary Public of the County of
State of North Carolina, hereby certify that _ � Q 161 C .C V Y`Q I l _ �`te. _ 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 Apir
y'ri�yfil/lilurf„I `
.y
Seal
iE My commission expires S 5 .a
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