NCC221077_FRO Submitted_20220317

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Southerland Mills
2. Location of land -disturbing activity: City or Township Wilson's Mills
Highway/Street Southerland Road Latitude 35.609278 Longitude-78.349608
3. Approximate date land -disturbing activity will commence: Summer 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 164.64 ac.
6. Amount of fee enclosed: $ 20,350.00 ' . The application fee of $330.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $110 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 Doug Lawrie E-mail Address [e-mail]
Telephone [phone] Cell # 919-746-6048 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Capital Properties of Raleigh IX, LLC 910-233-8581
Name Telephone
NIA
Fax Number
3724 National Drive, Suite 220 3724 National DRive, Suite 220
Current Mailing Address Current Street Address
Raleigh _ NC 27612 Raleigh NC 27612
City State Zip City State Zip
10. Deed Book No. 5515 Page No. 630
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):
Capital Properties of Raleigh IX, LLC _andy@shenandoahhomesms
Name E-mail Address
3724 National Drive, Suite 220 3724 National Drive, Suite 220 W
Current Mailing Address Current Street Address
Raleigh [VC 27612 Raleigh NC 27612
City State Zip City State Zip
Telephone [phone] Fax Number NIA

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
E-mailAddress
Current Street Address
State Zip City
Telephone Fax Number.
State Zip
(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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State
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.
David Stallings
Type or print name
Signature
Registered Agent
Title or Authority
6/25/21
Date
I, Konstantina Bakatsias , a Notary Public of the County of
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
Wake
David Stallings appeared
duly sworn acknowledged that the above form was
Witness my hand and notarial seal, this 25 day of .tune , 20 21
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My commission expires 9/15/2025