NCC222448_FRO Submitted_20220707

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 ELLER TRACT SUBDIVISION
2. Location of land -disturbing activity: City or Township WILDERS
Highway/Street 3490 NC HWY 231 Latitude 35.73912 Longitude-78.30559
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 28.47
6. Amount of fee enclosed: $ 6,175 . 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 E-mail Address
Nick McKeel [e-mail]
Telephone [phone] cell # NIA Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
STRICKLAND HINTON, LLC
Name Telephone Fax Number
114 W MAIN STREET STE 102
Current Mailing Address Current Street Address
CLAYTON NC 27520
City State Zip City State Zip
10. Deed Book No. 06240 Page No. 0594
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):
STRICKLAND HINTON, LLC [e-mail]
Name E-mail Address
114 W MAIN STREET STE 102
Current Mailing Address Current Street Address
CLAYTON NC 27520
City State Zip City State Zip
Telephone [phone] Fax Numbe

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:
NIA
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA NIA NIA
NIA NIA NIA
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
(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:
NIA
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA NIA NIA
NIA NIA NIA
City State Zip
City State Zip
Telephone N/A Fax Number N/A
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.
Reid Smith Managing Member
Type or print name Title or Authority
2. 2D 2-
Si ature Date
I, , a Notary Public of the County of tl V a
State of North Carolina, hereby certify that _ 4 t T A 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 2 l Stday of _"S V V` e, , 20 ZZ
t 5; L MO
d"''l
O'1ARY
Seal ON 8
U
PUBS-�G 2
COV
Notary
My commission expires