NCC232363_ESC Approval Submitted_20230811

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 Rains Preserve
2. Location of land-disturbing activity: City or Township Pikeville
Highway/Street Rains Crossroad Latitude 35.520 Longitude -78.105
3. Approximate date land-disturbing activity will commence: June 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.94
6. Amount of fee enclosed: $ 1,520 . 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 ❑X No Enclosed LJ
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kevin Varnell E-mail Address [e-mail]
Telephone [phone] Cell# (252)-382-0012 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Donna Boyette O'Neal 919-934-9941
Name Telephone Fax Number
25 Carmil Drive 25 Carmil Drive
Current Mailing Address Current Street Address
Selma, NC 27576 Selma, NC 27576
City State Zip City State Zip
10. Deed Book No. 2838 Page No. 0014
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):
Donna Boyette O'Neal [e-mail]
Name E-mail Address
25 Carmil Drive 25 Carmil Drive
Current Mailing Address Current Street Address
Selma, NC 27576 Selma, NC 27576
City State Zip City State Zip
Telephone [phone] Fax Number

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.
Donna Boyette O'Neal
Owner
Type or print name Title or Authority
y ;(Gf' , 0"(e� _2/27/2023
Signature Date
I, nn'vrer Mae-1 u.ny ors , a Notary Public of the County of J®hn5101)
State of North Carolina, hereby certify that Donna FJO P� t'(leal appeared personally
before me this day and being duly sworn acknowledged thaNhe above form was executed by him/her.
Witness my hand and notarial seal, this 2:7441 day of Februa.ri , 20 23
45;1,�.�, JEN[alFfffi MAE RUNYON r�Nl/ril �1U�
Notary Public, North Carolina ' ta J �VJ
�► ,1 Johnston County ry
'Ally Commission Expires
ti--►' duly 16,2024 My commission expires JUJ...A J 1 to, 2-02L