NCC220808_FRO Submitted_20220310

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 High Springs at Swift Creek - Phase 1
2. Location of land -disturbing activity: City or Township Cleveland Township
Highway/Street
SR 1010 -Cleveland Road Latitude Longitude 35.55540-78.47030
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): 36.72
6. Amount of fee enclosed: $ 7,1 75.00 . 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.
/. 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 Harold G. Carroll, Jr. E-mail [e-mail]
Telephone [phone] Cell # NIA Fax # (919) 639 - 3469
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Jones Creek, L.L.C. (919) 639 - 3281
(919) 639 - 3469
Name
Telephone Fax Number
63 Veron Court
63 Veron Court
Current Mailing Address
Current Street Address
Willow Springs NC
27592 Willow Springs NC 27592
City State
Zip City State Zip
10. Deed Book No. 05904
Page No. 0557
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):
Jones Creek, L.L.C.
[e-mail]
Name
E-mail Address
63 Veron Court
63 Veron Court
Current Mailing Address
Current Street Address
Willow Springs NC
27592 Willow Springs NC 27592
City State
Zip City State Zip
Telephone (919) 639 - 3281 Fax Number (919) 639 - 3469

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Caroiina Agent:
N A 1 A
Na a E- ail Address
MIA
Current Mailing Address
u 1A
Cit state Zip
Telephone — --A—,
u 1A
Cu rent Street Address
� A
city state zip
Fax Number
P 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-
A A
Nape of Registered Agent E-mail Address
A 11.1A
Cu rent Mailing Address Cu ent Street Address
&I 1A 9 1A
City State Zip Cit
State Zip
Telephone !�
Fax Number A I A
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.
Type or print name Title or Authority!!
Signatur pate
11PA4 , a Notary Public of the County of a
State of North Carolina, hereby certify that rod CT. 0 arro.1 I appeared
personally before me this day and being duly sworn acknowledged that the above form was
exec utN44W 4�,
�.•N ante N. %,, l� 11A�
'+ aryr-he gotarial seal, this _day of t1 /► 0
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