NCC222081_FRO Submitted_20220604

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 Water View Landing
2.
3.
4.
Location of land -disturbing activity: City or Township Boon Hill
Highway/Street Stevens Chapel Road Latitude 35.46498 Longitude-78.24301
Approximate date land -disturbing activity will commence: May 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.25
6. Amount of fee enclosed: $ 1,520.00 . 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.
7. 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 Jackie Robertson E-mail Address [e-mail]
Telephone Cell # 919-497-6906 Fax #
W
10
Landowner(s) of Record (attach accompanied page to list additional owners):
Robmir, Inc. 919-497-6906
Name Telephone Fax Number
100 S. Smithfield Road 100 S. Smithfield Road
Current Mailing Address
Knightdale NC
City State
Deed Book No. 5956
Part B.
Current Street Address
27545 Knightdale
Zip City
Page No. 761-764;770-773
NC
State
27545
0
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):
Robmir, Inc. [e-mail]
Name E-mail Address
100 S. Smithfield Road 100 S. Smithfield Road
Current Mailing Address Current Street Address
Knightdale NC 27545 Knightdale NC 27545
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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.
Jackie Robertson
pe or print name
SigrMture
Vice President
Title or Authority
4-27-2022
Date
Steven S. Sanderson , a Notary Public of the County of
Wake
State of North Carolina, hereby certify that Jackie Robertson appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 27 day of April 20 2022
Steven S. Sanderson
NotP bfic
WakeCoty, NC Z�
M Commission Ex ires '
Notary
My commission expires 11-3-2022