NCC223666_FRO Submitted_20221102

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_ The Reserve at Satterfield Farm
2. Location of land -disturbing activity: City or Township_ Pleasant Grove, Johnston County
Highway/Street_ SR 1531 . Latitude_ N35.56091288 L,Dngitude_ W78.63492549
3. Approximate date land -disturbing activity will commence:_ Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential _
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 2.9 AC.
6. Amount of fee enclosed: $ 1,140.00 . The application fee of $380.uu 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_
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Williams Builders of Rocky Mount, LLC E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Williams Builders of Rocky Mount, LLC [phone]
Name Telephone Fax Number
8820 Thomas Rd Same
Current Mailing Address Current Street Address
Rocky Mount NC 27803 Same
City State Zip City State Zip
10. Deed Book No. 06127 Page No. 0619
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):
Williams Builders of Rocky Mount, LLC [e-mail]
Name
8820 Thomas Road
Current Mailing Address
E-mail Address
Same
Current Street Address
Rocky Mount, NC 27803 Same
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 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:
David Williams
Name of Registered Agent
8820 Thomas Road
Current Mailing Address
Rocky Mount, NC 27803
City State
Telephone [phone]
91
[e-mail]
E-mail Address
8820 Thomas Road
Current Street Address
Rocky Mount, NC 27803
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.
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a Notary Public oft e C unty of I A
State of North Carolina herebycertify that /'�I G�-f►"r-S appeared
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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 _q_�day of 2--c-A-4,A4A­ 200U
DIANA HOLLAND No ry
fV@ Y PUBLIC
WI1.3) 00WY, NC My commission expires � �d
My Ce nmlfrlon Expire# 3.24.2025