NCC221585_FRO Submitted_20220425

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.)
Part A.
1. Project name Annandale Phase 2/3
2. Location of land -disturbing activity: City or Township Cleveland
Highway/Street Cornwallis Rd. Latitude Longitude
3. Approximate date land -disturbing activity will commence: 11 /19
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 83.78
6. Amount of fee enclosed: $ $10,400 . The application fee of $300.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $100 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:
Z4Cfa
Name z�-,�►a ic,�+�.,� E-mail Address sir
Telephone ��� 2 '� f�a✓ Cell # q i�a Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
�A�t rf}L �i�aPrw��tc_S nF
Name Telephone Fax Number
Current Mailing Address Current Street Address
T_ -4L15= 16 -N- t'J - -Z_-7 (' 12- 7 AA- "' 6
City State Zip City State Zip
10. Deed Book No. 04809 Page No. 0066
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
rmmn-fipnsive list of all responsible parties on an attached sheet):
?r t:XL�h\
Name J E-mail Address
iJATIL> Ati ,71t. S7TC � 0 iQY+-tar
Current Mailing Address Current Street Address
City State Zip City State zip
Telephone 171 `7 Y � ('9 " � ��� 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State \ Zip City
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
City
Telephone
E-mail Address
Current Street Address
State Zip 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
�.,rrA�tpd information should there be any change in the information provided herein.
U�r�int
S�
`Type or ame
Si
A
Title or Authority
Date
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I, Le-6 a r� c��o►InP ck w , a Notary Public of the County of
State of North Carolina, hereby certify that ��� t appeared
personally before me this day and being y sworn ac nowledg d that the above form was
executed by him.
Witness my hand and notarial seal, this _day of
20-21—
Seal Z
M commission expires
achary aupp orty
Notary Publlc
Onslow Gounty
My Commissionxr�rens 5�22/2023