NCC232249_FRO Submitted_20230727

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Timothy G. Broome WTP 18-MGD Expansion
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Johnston City or Township Wilson's Mills
Clearwater Drive 35.5816 -78.3307
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: May 15, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal WTP
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.2
6. Amount of fee enclosed: $800 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kim Rineer E-mail Address [e-mail]
Phone: Office# 919-989-5725 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Johnston County
Name Phone: Office# Mobile#
PO Box 2263 309 E. Market Street
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
10. Deed Book No. 01405 Page No.0530 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
Johnston County (do Rick Hester) [e-mail]
Company Name E-mail Address
PO Box 2263 309 E. Market Street
Current Mailing Address Current Street Address
Smithfield, NC 27577 Smithfield, NC 27577
City State Zip City State Zip
Phone: Office# 919-989-5100 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office# Mobile#
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Rick J. Hester County Manager
Ty!. 'ry=;,.." Title or Authority
Signs - Date
I, Susan L. Qezyes , a Notary Public of the County of �ihns
State of North Carolina, hereby certify that ��C•� kf_Skr appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 21 day of MOJ Ch , 20 a�
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101 V. My commission expires ���� 0
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AGENT AUTHORIZATION FORM
PROPERTY DESCRIPTION:
The Johnston County Department of Public Utilities proposes to expand the T.G. Broome Water
Treatment Plant in Johnston County, North Carolina.
STREET ADDRESS: 600 Clearwater Drive, Smithfield, NC 27577
PROPERTY OWNER: Johnston County
The undersigned, Chandra Farmer, on behalf of the Johnston County Department of Public
Utilities, do hereby authorize
Linda Diebolt o f Hazen and Sawyer
(Contractor/ Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached, excluding any
and all financial obligations.
SIGNATORY'S ADDRESS:
Rick Hester
Manager
Johnston County
207 Johnston Street
P.O. Box 1049
Smithfield, NC 27577
[phone]
I hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature:
Date:

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