NCC222926_FRO Submitted_20220818

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 Knoll View Subdivision
2. Location of land -disturbing activity City or Township Elevation Township
Highway/Street
SR 1336 - Lakewood Road Latitude 35.51470Longitude -78.49720
3. Approximate date land -disturbing activity wilt commenceUpon receipt of permit.
4. Purpose of development (residential. commercial, industrial. institutional, etc.): Residential
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas). 6.78 acres
6. Amount of fee enclosed $ 2,660.00 . 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___0_ Enclosed__ ,,_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Ronnie Roberts E-mail Address ronnie@robcoreside ntial com
Telephone( 919 ) 894 - 9904 Cell # ( 919 ) 427 - 5203 Fax 4 NIA
9.
Landowner(s) of Record (attach accompanied page to list additional owners)
Ronnie Roberts ( 919 ) 894 - 9904
Name
5750 NC Highway 50
Current Mailing Address
Benson NC
City State
10, Deed Book No. 05911
Telephone
5750 NC Highway 50
Current Street Address
=75� Benson NC
Zip City State
Page No 0400
NIA
Fax Number
27504
Zip
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):
Ronnie Roberts [e-mail]
Name E-mail Address
5750 NC Highway 50 5750 NC Highway 50
Current Mailing Address Current Street Address
Benson NC 275Cp Benson NC 27504
City State Zip City State Zip
Telephone( 919 ) 894 - 9904 Fax NurnberN/A

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
N/A NIA
Current Mailing Address Current Street Address
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 N/A
Name of Registered Agent E-mail Address
N/A NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
Telephone NIA 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 informatio there be any changle in the information provided herein.
Ronnie R ert Owner
Type or e Title or Authority
1 /14/22
Sio ature Date
I, rf a Notary Pub o, of the C-91mV of J�hrrby —
State of North Carolina, hereby cerfity thai 20not jV _ appeared
personally before me this day and being duly sworn a(Knowiedged Vnat the above form was
executed by him,
Witness my hand and notarial seal, this day of i LG��'( 20 31)
e"e1eypleHeelehp, y11II. 4
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Notary
Uj = Seal
My commission expires "
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