NCC223243_FRO Submitted_20220927

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 Charlestowne Phase 3
2. Location of land -disturbing activity: City or Township Smithfield
Highway/Street Bayberry Latitude 35.441968 Longitude 78.277788
3. Approximate date land -disturbing activity will commence: 05/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 21.60
5�6. Amount of fee enclosed: $ The application fee of $3XO.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $Yrb er acre for each
additional acre (rounded up to the next acre). /90
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity. -
Name Nick Tsakanikas E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Adams Homes AEC LLC
919-233-6747
Name
Telephone Fax Number
100 W Garden St.
100 W Garden St. 2nd Floor
Current Mailing Address
Current Street Address
Pensacola FL 32502
City State Zip
City State Zip
10. Deed Book No.41 88 Page No. 569
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):
Adams Homes AEC LLC
[e-mail]
Name
E-mail Address
149 U.S. Hwy. 70 W.
149 U.S. Hwy. 70 W.
Current Mailing Address
Current Street Address
Garner NC 27527
Garner NC 27527
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:
Nick Tsakanikas
Name
149 U.S. Hwy. 70 W.
Current Mailing Address
Garner NC 27527
City
State Zip
Telephone [phone]
[e-mail]
E-mail Address
149 U.S. Hwy. 70 W.
Current Street Address
City State Zip
Fax Number 919-233-6780
(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 be any change in the information provided herein.
Nick Tsakanikas
General Manager Raleigh
Type or print name Title or Authority
s I IZ"Z
Signat li Date
------------------------------------------------------------------------------------------------------------------------------------
I, I� LJkCrnCjAQrlC > D IJA-7� , a Notary Public of the County of
State of North Carolina, hereby certify that N/ut TS,4kA#JtKA=T 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 Z! _day of t:AW 202,2
r�o OT ARJ''�9` Notary
mm. Exp. =
5Z7-2024 = c My commission expires J

JOHNSTON COUNTY EROSION and SEDIMENTATION CONTROL PLAN PRELIMINARY REVIEW CHECKLIST
The following items shall be incorporated with respect to specific site conditions, in an erosion & sedimentation control plan:
NPDES Construction Stormwater General Permit NCG010000
X Designation on the plans where the 7 or 14 day ground stabilization requirements apply per Section II.B.2 of the permit.
X Design of basins with one acre or more of drainage area for surface withdrawal as per Section II.B.4 of the permit.
LOCATION INFORMATION X Name and classification of receiving water course or name of
municipal operator (only where stormwater discharges are to
X Project location & labeled vicinity map (roads, streets, landmarks) occur)
X North arrow and scale
X Provide a copy of site located on applicable USGS quadrangle and STORMWATER CALCULATIONS
NRCS Soils maps
GENERAL SITE FEATURES (Plan elements)
X Property lines & ownership ID for adjoining properties
X Existing contours (topographic lines)
X Proposed contours
X Limits of disturbed area (provide acreage total, delineate limits,
and label). Be sure to include all access to measures, lots that will
be disturbed, and utilities that may extend offsite.
Planned and existing building locations and elevations
x Planned & existing road locations & elevations, including
temporary access roads
X Lot and/or building numbers
x Hydrogeologic features: rock outcrops. seeps, springs, wetland
and their limits, streams, lakes, ponds, dams, etc. (include all
required local or state buffer zones and any Riparian Buffer
determinations)
x Easements and drainageways, particularly required for offsite
affected areas. Include copies of any recorded easements and/or
agreements with adjoining property owners.
Profiles of streets, utilities, ditch lines. etc.
_ Stockpiled topsoil or subsoil locations
X If the same person conducts the land -disturbing activity & any
related borrow or waste activity. the related borrow or waste
activity shall constitute part of the land -disturbing activity unless
the borrow or waste activity is regulated under the Mining Act of
1971, or is a landfill regulated by the Division of Waste
Management. If the land -disturbing activity and any related
borrow or waste activity are not conducted by the same person.
they shall be considered separate land -disturbing activities and
must be permitted either through the Sedimentation Pollution
Control Act as a one -use borrow site or through the Mining Act.
x Location and details associated with any onsite stone crushing or
other processing of material excavated. If the affected area
associated with excavation, processing, stockpiles and transport
of such materials will comprise 1 or more acres, and materials will
be leaving the development tract, a mining permit will be required.
x Required Army Corps 404 permit and Water Quality 401
certification (e.g. stream disturbances over 150 linear feet)
EROSION & SEDIMENT CONTROL MEASURES (on plan)
X Legend (provide appropriate symbols for all measures and
reference them to the construction details)
x Location of temporary measures
X Location of permanent measures
X Construction drawings and details for
temporary and permanent measures. Show measures to scale on
plan and include proposed contours where necessary. Ensure
design storage requirements are maintained through all phases of
construction.
Maintenance requirements for measures
x Contact person responsible for maintenance
SITE DRAINAGE FEATURES
X Existing and planned drainage patterns (include off -site areas that
drain through project and address temporary and permanent
conveyance of stormwater over graded slopes)
x Method used to determine acreage of land being disturbed and
drainage areas to all proposed measures (e.g. delineation map)
X Size, pipe material and location of culverts and sewers
X Soil information: type, special characteristics
X Soil information below culvert storm outlets
x Pre -construction runoff calculations for each outlet from the site (at
peak discharge points). Be sure to provide all supporting data for
the computation methods used (rainfall data for required storm
events. time of concentration/storm duration, and runoff
coefficients).
x Design calculations for peak discharges of runoff (including the
construction phase & the final runoff coefficients for the site)
" Design calcs for culverts and storm sewers (include HW, TW and
outlet velocities)
X Discharge and velocity calculations for open channel and ditch
flows (easement & rights -of -way)
Design calcs for cross sections and method of stabilization for
existing and planned channels (include temporary linings). Include
appropriate permissible velocity and/or shear stress data.
x Design calcs and construction details for energy dissipaters below
culvert and storm sewer outlets (include stone/material specs &
apron dimensions). Avoid discharges on fill slopes.
Design calcs and dimension of sediment basins (note current
surface area and dewatering standards as well as diversion of
runoff to the basins). Be sure that all surface drains, including
ditches and berms, will have positive drainage to the basins.
VEGETATIVE STABILIZATION
Area & acreage to be stabilized with vegetation
Method of soil preparation
Seed type & rates (temporary & permanent)
Fertilizer type and rates
Mulch type and rates (include mulch anchoring methods to be
used)
NOTE: Plan should include provisions for groundcover in accordance with
NPDES Construction Stormwater General Permit NCG010000
and permanent groundcover for all disturbed areas within 15
working days or 90 calendar days (whichever is shorter) following
completion of construction or development.
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
X Completed. signed & notarized FR/O Form
X Accurate application fee payable to Johnston County Public
Utilities
X Certificate of assumed name. if the owner is a partnership
X Name of Registered Agent (if applicable)
Copy of the most current Deed for the site. Please make sure the
deed(s) and ownership information are consistent between the
plan sheets. local records and this form.
X Provide latitude & longitude (in decimal degrees) at the project
entrance.
NARRATIVE AND CONSTRUCTION SEQUENCE
Narrative describing the nature & purpose of the construction
activity
Construction sequence related to erosion and sediment control
(including installation of critical measures prior to the initiation of
the land -disturbing activity & removal of measures after areas they
serve are permanently stabilized). Address all phases of
construction and necessary practices associated with temporary
stream bypasses and/or crossings.
Bid specifications related only to erosion control
JCPU ESC August 2013