NCC223957_FRO Submitted_20221206

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.
Project Name NE Flowers Parkway and Commercial
Location of land -disturbing activity: City or Township Flowers Plantation
Highway/Street NC HWY 42 Latitude 35.655740 Longitude-78.342749
Approximate date land -disturbing activity will commence: Fall 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential/Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25 Ac.
Amount of fee enclosed: $ 5,675.00 . 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).
Has an erosion and sediment control plan been filed? Yes No Enclosed_X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andrew Stocks E-mail Address astocksastocksengineering.com
Telephone
252-459-8196 Cell # 252-450-5140 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Flowers Holdinq Company LLC
Name
4880 NC 42 East
Current Mailing Address
Clayton NC 27520
City State Zip
[phone] 252.459.8197
Telephone Fax Number
Same
Current Street Address
City State Zip
10. Deed Book No. 01789 Page No. 0784
Part B.
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):
Flowers Holdina Comoanv LLC
Name
4880 NC 42 East
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone [phone]
rflowersa-flowersplantation.com
E-mail Address
Current Street Address
City State Zip
Fax Number 252.459.8197

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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephon
E-mail Address
Current Street Address
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.
Rebecca Flowers Owner
Ty o print name Title or Authority
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Signatu e Date
I, -Kk1i &kCLej S4t)6.s , a Notary Public of the County of
State of North Carolina, hereby certify that ZGhGGGo, '(OwCeS appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
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