NCC231060_FRO Submitted_20230419

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,
2.
Project Name Green Pines Estates
Location of land -disturbing activity: City or Township Kenly
Highway/Street NC Highway 222 W Latitude 35.6279° N Longitude 78.1506° W
3. Approximate date land -disturbing activity will commence:
4.
Fall 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.77 Ac.
6. Amount of fee enclosed: $ 1 , 140.00 . 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 z No 11 Enclosed✓
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ethan Averette E-mail Address [e-mail]
Telephone [phone]
Cell # 252-382-0012 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners).
AJ Flowers Finch, Inc. (919)-291-4838
Name Telephone Fax Number
4884 NC Highway 42 E 4884 NC Highway 42 E
Current Mailing Address Current Street Address
Clayton NC 27527 Clayton NC 27527
City State Zip City State Zip
10. Deed Book No. 6267 Page No. 585
Part B.
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):
J&J Flowers Finch, Inc. [e-mail]
Name E-mail Address
4884 NC Highway 42 E 4884 NC Highway 42 E
Current Mailing Address Current Street Address
Clayton NC 27527 Clayton NC 27527
City State Zip
Telephone [phone]
City State Zip
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 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.
T p or print name Title or Authority
1A Le-
Signaturel Date
'gel',
a Notary Public of the County of __ oh^s-V,
State of North Carolina, hereby certify that 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 6 fk day of 1�eeQ.w,4 d4 , 20 0� �
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