NCC230329_FRO Submitted_20230207

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 Eatmon's Landing Phase II
2. Location of land -disturbing activity: City or Township Wilders
Highway/Street Eatmon Road Latitude 35.70892 Longitude-78.30086
3. Approximate date land -disturbing activity will commence: January 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1 .92
6. Amount of fee enclosed: $ 760.00 . 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). 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 Jackie Robertson
E-mail Address [e-mail]
Telephone
Cell # 919-497-6906 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
JR Development LLC
919-497-6906
Name
Telephone Fax Number
100 S. Smithfield Road
100 S. Smithfield Road
Current Mailing Address
Current Street Address
Knightdale NC
27545 Knightdale NC 27545
City State
Zip City State Zip
10. Deed Book No. 6376
Page No. 512-514
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):
JR Development LLC
[e-mail]
Name
E-mail Address
100 S. Smithfield Road
100 S. Smithfield Road
Current Mailing Address
Current Street Address
Knightdale NC
27545 Knightdale NC 27545
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
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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
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.
Jackie Robertson
Ty or print name
LA4�_
SignattUe
11 Steven S. Sanderson
State of North Carolina, hereby certify that -
personally before me this day and being
executed by him.
Witness my hand and notarial seal, this
Steven S. Sanderson
Notary Pi tbli,.
Wq ' urty, NC M
RIX Commission xfires - 3
Managing Member
Title or Authority
11-22-2022
Date
a Notary Public of the County of Wake
Jackie Robertson appeared
duly sworn acknowledged that the above form was
22 day of November 202022
Notary
My commission expires 11-3-2027