NCC221141_FRO Submitted_20220328

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 NIA in the blank.)
Part A.
1. Project Name HAMPTON
2. Location of land -disturbing activity: City or Township FOUR OAKS
Highway/Street NC HWY 21C Latitude 35.5100 Longitude--78.5237
3. Approximate date land -disturbing activity will commence: JULY 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
24.90 AC
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2A . gg-2 �
6. Amount of fee enclosed: $ 4, 950 . 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 x Enclosed YES
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name NICHOLAS HA�ILTON E-mail Address LAWNCARE4 CASH@ GMAIL. COM
Telephone Cell # 919-279-8033 Fax #
9-1
Landowner(s) of Record (attach accompanied page to list additional owners):
FOUR C'S OF JOHNSTON COUNTY, LLC 910-591-9945
Name Telephone
221 DOGEYE RD
Current Mailing Address
BENSON NC 27504
City
State Zip
109 MEADOWBROOK CT
Current Street Address
Fax Number
BENSON NC 27504
City State Zip
10. Deed Book No. 05761 Page No. 0214
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):
FOUR C'S OF JOHNSTON COUNTY, LLC [e-mail]
Name E-mail Address
221 DOGEYE RD 109 MEADOWBROOK CT
Current Mailing Address
BENSON NC
City
State
Telephone [phone]
Current Street Address
27504 BENSON
Zip City
Fax Number
NC 27504
State Zip

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
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
ANLREW PHILLIPS
Type or print name
Signature
MANAGING MEMBER
Title or Authority
5/ . 11 l i
Date ^�
(1ZZ fd r'«%l<�.J a Notary Public of the County of
State of North Carolina, hereby certify that -�L�! _ appeared
personally before me this day and being duly sworn acknowledgl4d that the above form was
executed by him.
Witness my hpi' q and notarial seal,
AB I p
Notasy Public _
Johnsltp-ounty
UEr1CIARmO�
this day of 2042
Notary
My commission expires