NCC222809_FRO Submitted_20220808

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville (Title 9, Chapter 8) before this form and an
acceptable erosion and sedimentation control plan have been completed and approved by the City of
Greenville, Engineering Division. (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 Farrington Trace Senior
2. Location of land -disturbing activity: County Pitt City or Township Greenville
Highway/Street Fire Tower Rd. Latitude 35.569815 Longitude-77.346358
3. Approximate date land -disturbing activity will commence: May 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4 acres
6. Amount of fee enclosed: $ 400.00 . The application fee of $100.00 per acre (rounded
to the tenth of acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $900).
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:
Name Scott T. Anderson, P.E. E-mail Address scott(o)arkconsultinggroup.com
Telephone [phone] Cell # 252-258-0734 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bobby W. Joyner 252-756-4964
Name Telephone Fax Number
1510 Trafalgar Drive
Current Mailing Address Current Street Address
Greenville NC 28590
City State Zip City State Zip
10. Deed Book No. 00000E Page No. 00556 Provide a copy of the most current deed.
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):
Farrington Trace Senior, LLC [e-mail]
Name E-mail Address
PO Box 566
Current Mailing Address
631 Dickinson Avenue
Current Street Address
Greenville NC 27835 Greenville NC 27835
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 State Zip
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 by any change in the information provided herein.
btjsTtN T. IMOkS
Type or print name
Signature
0whic�
Title or Authority
2. !D. cz
Date
-------------------------------------------------------------------------------------------
I Jet'1q -�v L ' H 2 �t a Notary Public of the County of
-Pi4
State of North Carolina, hereby certify that U5��'" l S 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 10 day of NJ PYyC,�\ 20 22
AMHarris tary*!�)_
eal�,n My commission expires% I Vusion 2025