NCC230906_FRO Submitted_20230403

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. Project Name Hearon Pointe
2. Location of land -disturbing activity: City or Township Cleveland Township
Highway/street Cleveland Rd Latitude 35.55177 Longitude -78.46522
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 25.02
6. Amount of fee enclosed: $ 5,800 . 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:
Namdames Lipscomb E-mail Address [e-mail]
Telephone [phone] cell # N/A Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners). -
Carriage Creek, LLC
NIA NIA
Name
Telephone Fax Number
PO Box 133
NIA
Current Mailing Address
Current Street Address
Clayton NC
27528 NIA NIA
NIA
City State
Zip City State
Zip
10. Deed Book No. 06369
Page No. 0489
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):
Carriage Creek, LLC
[e-mail]
Name
E-mail Address
PO Box 133
NIA
Current Mailing Address
Current Street Address
Clayton NC
27528 NIA NIA
NIA
City State
Zip City State
Zip
Telephone [phone]
Fax Number N/A

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:
N/A N/A
Name
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A N/A
NIA N/A N/A N/A
City State
Zip City State Zip
Telephone N/A
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
N/A
Name of Registered Agent
E-mail Address
N/A
N/A
Current Mailing Address
Current Street Address
N/A N/A
NIA NIA N/A N/A
City State
Zip City State Zip
Telephon
N/A Fax Number N/A
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.
James Lipscomb
Type or pri► "me
Signature
Managing Member
Title or Authority
Date
I, iM i (k 11A . � (Lh 6W a Notary Public of the County of �Dh sw
State of North Carolina, hereby certify that k r 6 lit IY P M � appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
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