NCC223841_FRO Submitted_20221121

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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
2
3
4
5
Project Name HEWITT WOODS Ph 1
Location of land -disturbing activity: City or Township CLAYTON TOWNSHIP
Highway/Street POWHATAN RD Latitude 35.61512 Longitude-78.38897
Approximate date land -disturbing activity will commence: ASAP
Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.72
6. Amount of fee enclosed: $ 3,420 . 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-
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name NATHAN EVANS E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
POWHATAN PARTNERS, LLC 919-345-6729 NIA
Name Telephone Fax Number
1130 SITUS CT, SUITE 244 1130 SITUS CT, SUITE 244
Current Mailing Address Current Street Address
RALEIGH NC 27606 RALEIGH NC 27606
City State Zip City State Zip
10. Deed Book No. 061 71 Page No. 0047
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):
POWHATAN PARTNERS, LLC [e-mail]
Name E-mail Address
1130 SITUS CT, SUITE 244 1130 SITUS CT, SUITE 244
Current Mailing Address Current Street Address
RALEIGH NC 27606 RALEIGH
City State Zip City
Telephone [phone] Fax Number NIA
NC
State
27606
Zip

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.—.�-----
NIA N_/A _
Current Mailing Address — Current Street Address
_N/A _ NIA NIA NIA NIA N/A
City State Zip City State Zip
Telephone NIA , Fax Number NIA
(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;
N/A
Name of registered Agent
N/A _
Current Mailing Address
NIA NIA
City
Telephone N/A
NIA
E-mail Address
NIA
Current Street Address
NIA NIA
State Zip City
Fax Number NIA
N/A N/A
State _ Zip
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.
Nathan Evans f o,6 ti--� Managing Member
Type or prin name Title or Authority
Signature �--� �- Date ---- -� ----- -
1, U 1(_v d_ R - act_o �S____, a Notary Public of the County of
State of North Carolina, hereby certify that ' can appeared
personally before me this clay and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this ___day of AuvA , ,_�_ 20,)a.
1
tiottand RAdarns LiL__
No PuW Notary
Ion County
Nett Carolina r�-I
M Corr+mtasion My commission expires—ja. - G