NCC230079_FRO Submitted_20230112

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 Drillers Service
2. Location of land -disturbing activity: City or Township Princeton NC
Highway/StreetAmlt Dr Latitude35.46768 Longitude-78.19963
3. Approximate date land -disturbing activity will commence. 1 0-17-22
4 Purpose of development (residential, commercial, industrial, institutional, etc.) commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 2
6. Amount of fee enclosed: $ 2280 . 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 Dale Sparks E-mail Address [e-mail]
Telephone [phone] Cell # 919-427-4493 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Curl Properties, LLC 931-389-6996
Name Telephone Fax Number
PO BOX 8 505 W Blackman Blvd
Current Mailing Address Current Street Address
Wartrace TN 37183 Wartrace TN 37183
City State
10. Deed Book No. 6072
Part B.
Zip City
Page No 150
State
Zip
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):
Curl Properties, LLC [e-mail]
Name E-mail Address
PO BOX 8 505 W Blackman Blvd
Current Mailing Address Current Street Address
Wartrace TN 37183 Wartrace TN 37183
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:
Dale Sparks
Name
PO BOX 405
Current Mailing Address
Smithfield NC 27577
City
[e-mail]
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
Fax Number
State Zip
(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.
Greg Curl
Type or print name
C�
Signature
-------------------------------------
Member
Title or Authority
Date
I, a Notary Public of the County of
State of del+roa hereby certify that appeared
personally before me this day and being duly swhm acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this rl day of „_.Ce, 20'1�4
STATE Notary
Seal OF
TENNESSEE My commission expires lr7 oZ0 -aJ�
NOTARY
�. PUBLIC
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