NCC232755_FRO Submitted_20230913

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 Neuse Colony WVVfP Expansion
2. Location of land-disturbing activity: City or Township Wilders
Highway/Street 2060 NC HWY 42 Latitude 35.6468 Longitude -78.4046
3. Approximate date land-disturbing activity will commence: October 1, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.71
6. Amount of fee enclosed: $ 760.00 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andrew Norris, PE E-mail Address ABNorns�a?aquaarnerica.com
Telephone#[phone] Cell#910-309-1096 Fax# [phone]
9 Landowner(s)of Record (attach accompanied page to list additional owners)
Aqua North Carolina. Inc 919-653-6975
Name Telephone Fax Number
202 MacKenan Drive 202 MacKenan Drive
Current Mailing Address Current Street Address
Cary NC 27511 Cary NC 27511
City State Zip City State Zip
10. Deed Book No 01829 Page No.0784
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):
Aqua North Carolina. Inc. abnorris(c�aquaamerica.com
Name E-mail Address
202 MacKenan Drive 202 MacKenan Drive

Current Mailing Address Current Street Address
Cary NC 27511 Cary NC 27511
City State Zip City State Zip
Telephone [phone] Fax Number 919-460-1788
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
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
CT Corporation System N/A
Name of Registered Agent E-mail Address
160 Mine Lake Road, Suite 200 160 Mine Lake Road, Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
Telephone 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.
Lauren Raup-Plummer Engineering Manager, Aqua NC, Inc.
Type o rint name Title or Authority
61- 7,,
Signature Date
I, � t� �� ,V� � \\ a Notary Public of the County of

State of North Carolina, hereby certify that L L\ c�v. -C
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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 \\, day of ,& 20c�—�
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