NCC230485_FRO Submitted_20230302

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 NIA in the blank.)
Part A.
1. Project Name Olde Place
2. Location of land -disturbing activity: City or Township O'Neals Township
Highway/streetAntioch Church Rd Latitude35-687 Longitude-78.296
3. Approximate date land -disturbing activity will commence: 2/1 /21 (Under NCC210315)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 53.22
6. Amount of fee enclosed: $150.00 Transfer. 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 Nick McKeel E-mail Address nick. mckeel 0 providence.constru ction
Telephone Cell # 919-429-0245 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Olde Place, LLC 919-901-3178
Name Telephone Fax Number
114 West Main Street 114 West Main Street
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
10. Deed Book No. 5951 Page No. 0153
Part B.
Person(s) or frm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Olde Place, LLC [e-mail]
Name E-mail Address
114 West Main Street 114 West Main Street
Current Mailing Address
C I ayto n NC 27620
City
Current Street Address
C I ayto n NC 27520
State Zip City
Telephone [phone]
Fax Number
State
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. -
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
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
State Zip
E-mail Address
Current Street Address
City State Zip
Telephone 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.
Reid Smith
Type or print name
Managing Member
Title or Authority
1 /23/2023
Sign re Date
z f 5 4 kL- �?- , a Notary Public of the County of
State of North Carolina, hereby certify that Lzco �� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
r
Witness my hand and notarial seal, this l?day of E� 4 , 20 z
CHRIS CAVALIER
S� NOTARY
Notary
canAina
My Commission Expires July 2.2024 My commission expires �2 Zb2