NCC222879_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 NIA in the blank.)
Part A.
1 . Project Name Willis Crossings
2. Location of land -disturbing activity City Township Town of Wilson's Mills
Highway/Street SR 1913 Latitude 35.57540 Longitude-78.34540
3. Approximate date land -disturbing activity will commence; Upon 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): 5.28
6. Amount of fee enclosed: $ Previously Paid The application fee of $275.00 per acre (rounded
up to the next acre) is assessed for the first 8 acres and an additional $72 per acre for each additional
acre (rounded up to the next acre).
7. Has an erosion and sediment control plan been filed? Yes Z No 1:1Enclosed_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kenneth R. Jones E-mail Address jonesrentalsr��embargmail.com
Telephone [phone] Cell 4 [phone] Fax [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kenneth R. Jones
[phone] [phone]
Name
Telephone Fax Number
P.O Box 208
NIA
Current Mailing Address
Current Street Address
Wilson's Mills NC
27593
NIA
City State
Zip
City State Zip
10. Deed Book No. 05041
Page No.
0882
05651
02139
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):
Kenneth R. Jones
jonesrentalsC.embargmail.coni
Name
E-mail Address
P.O Box 208
N/A
Current Mailing Address
Current Street Address
Wilson's Mills NC
27593
NIA
City State
Zip
City State Zip
Telephone [phone]
Fax Number [phone]

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
Name
NIA
Current Mailing Address
N/A
City State Zip
Telephone NIA
N/A
E-mail Address
NIA
Current Street Address
NIA
City State Zip
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
Name of Registered Agent
NIA
Current Mailing Address
NIA
NIA
E-mail Address
NIA
Current Street Address
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,
:1
Type or print name Title or Authority
G
y
'Signature Date
,a Notary Public of the County of �'�)bnsvun
State of North Carolina, hereby certify that 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 19 day of ®CA436er 20 7-I
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My commission expires I I lIZ17-4