NCC221871_FRO Submitted_20220517

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 Ford Meadows./ ofs /—#0
2. Location of land -disturbing activity: City or Township Garner
Highway/Street4150 NC Highway 42 W Latitude 35.61 291 8 Longitude-78•543513
3. Approximate date land -disturbing activity will commence: 12/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.98 Acres
6. Amount of fee enclosed: $ 1 ,900 . 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.
7. Has an erosion and sediment control plan been filed? Yes 17 No ❑ Enclosed��
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andy Crawford E-mail Address [e-mail]
Telephone [phone] Cell # `7/9- yZ7-296Z Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ford Meadows, LLC
Name Telephone Fax Number
5160 NC Highway 42 W
Current Mailing Address Current Street Address
Garner NC 27529-8417
City State Zip City State Zip
10. Deed Book No. 05781 Page No. 0584
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). -
Eastwood Homes of Raleigh LLC
Name E-mail Address
6601 Six Forks Road, Suite 100 6601 Six Forks Road, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] 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 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
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
corrected information should there be any change in the information provided herein,
Andy Crawford Vice President of Construction
Type or print name
Sign re
Title or Authority
/I61 Zcz z
Date
I, ArA6U I TO SerA a Notary Public of the County of LO
State of North Carolina, hereby certify that _ _ ROW Cfatx A appeared
personally before me this day and being duly s orn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this L9q, d
My commission expires-2-L,,,t,yp Q0& �_