NCC223499_FRO Submitted_20221013

DocuSign Envelope ID: 153D6E1 E-9929-48E0-92D1-7D84F0FD87AC
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.
Jones Farm Phase 3 Lots 1-14
1. Project Nam
Cleveland Township
2. Location of land -disturbing activity: City or Township
SR 1529 Angle Road 35.58915-78,61490
Highway/Street Latitude Longitude
October 2022
3. Approximate date land -disturbing activity will commence:
Residential
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
9.18
5, Total acreage disturbed or uncovered (including off -site borrow and waste areas):
1,400.00
6. Amount of fee enclosed: $ 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 El
E
Person to contact should erasion and sediment control issues arise during land -disturbing activity:
Brian Herring [e-mail]
Name E-mail Address
919-650-8224
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
DMS Partners, LLC 919-351-0091 919-573-0479
Name
PO Sox 129
Current Mailing Address
Pine Level NC 275
68
City State Zip
4823
10. Deed Book No.
Part B.
Page No,
Telephone Fax Number
214 North Peedin Avenue
Current Street Address
Pine Level NO 2756
8
City State Zip
485-488
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):
Herring Realty, LLC dba Herring Homes [e-mail]
Name E-mail Address
933 Old Knight Road 933 Old Knight Road
Current Mailing Address Current Street Address
Knightdale NC 275 Knightdale NO 2754
45 5
City State Zip City State Zip
919-650-8224
Telephone Fax Number

DocuSign Envelope ID: 153D6E1E-9929-46EO-9201-7D84EOFD67AC
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Thomas B. Herring [e-mail]
Name of Registered Agent E-mail Address
1070 N. Lakeside Drive 1070 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield NC 27 Smithfield NC 2757
57
City State Zip City State Zip
919-650-8224
Telephone 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.
Thomas Brian Herring
Managing Member
name Title or Authority
10/5/2022
Signa uie Date
T, f�«"I a Notary Public of the County of
Thomas Brian Herring
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.
October 22
Witness my hand and notarial seal, this day of , 20
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