NCC230984_FRO Submitted_20230414

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 Alder Creek Subdivision - Lot Clearing/Grading
2. Location of land-disturbing activity: City or Township Elevation
Latitude 35.44445 Longitude-78.56188
Highway/Street NC50
3. Approximate date land-disturbing activity will commence:4/1/2023
4. Purpose of development(residential, commercial,industrial, institutional, etc.):Rsidential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):43.2 ac
90 lots at$100 each
6. Amount of fee enclosed: $ . 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 Gordon Frieze E-mail Address [e-mail]
Telephone[phone] Cell# 910-262-5450 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Ben-Alder Creek, LLC 910-256-2514
Name Telephone Fax Number
PO Box 1328 6336 Oleander Dr. Suite 4
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480 Wilmington NC 28403
City State Zip City State Zip
10. Deed Book No.6077 Page No.35-46
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):
Ben-Alder Creek, LLC [e-mail]
Name E-mail Address
PO Box 1328 6336 Oleander Dr. Suite 4
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480 Wilmington NC 28403
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:
Sheri S. Smothers [e-mail]
Name E-mail Address
PO Box 1328 6336 Oleander Dr. Suite 4
Current Mailing Address Current Street Address
Wrightsville Beach NC 28480 Wilmington NC 28403
City State Zip City State Zip
910-262-5450
Tetephone 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. Jf the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City • State - Zip 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.
Sheri S. Smothers Manager
Type or print name Title or Authority
ignature Date
--)1.adv\ , a Notary Public of the County of 1\-V-^/ ettfirtikr43,-
(
State of North Carolina, hereby certify that CAL ‘S-G4 (Ltk`/SK‘ 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 5 C -day of ,20 13
Jason D Cline
Notary Public
New Hanover County,NC Notary
My commg§ton Expires 0110612026
My corn ission expires

BEN-ALDER CREEK LLC 6137
PO BOX 1328
66-1233531
•WRIGHTSVILLE BEACH NC 28480
DATE 313
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