NCC233097_FRO Submitted_20231020

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 SKVL.AR )i.4 toua SUBeivsS►o&l
2. Location of land-disturbing activity: City or Township Book! }%l/Lt Wm/QU!/P
Highway/Street ilia/st/G Zth Latitude 35.49n0 Longitude - 78. 19820
3. Approximate date land-disturbing activity will commence: dPo*/ RECEIPT of PG,04/r.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): aES1bea1T/AL-
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4./0
6. Amount of fee enclosed: $ 2,000.00 . The application fee of$400.00 per acre (rounded
up to the next acre) is assessed for the first 8 acres and an additional $125 per acre for each additional
acre (rounded up to the next acre).
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 RICKY ..& 4GV E-mail Address brad}/ 989 ao% corn
Telephone (919) 369- (DODO Cell # (919) 369- 6000 Fax# /J/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
le/cxl/ BRAD) (919) 369 - 6000 *I/A
Name Telephone Fa Number
989 Cowin AWE ZOISZ 909 touL/rRY' SrozE.. Z,4A
Current Mailing Address Current Street Address
6E4 4 ,VC. 27576 Sere Air., 27576
City State Zip City State Zip
10. Deed Book No. O2/O7 Page No. 0829
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):
IQ/cKy BRAar brad 989 ' ad. tom
Name E-mail A dress
989 CouvrRv SroRE. ga4o 989 Coum Y Srotz. ,Qom
Current Mailing Address Current Street Address
SELMA Mc- 27576 SE4_,.1.4 SIG 2 7C 74
City State Zip - City State Zip
Telephone (9/9) 36•9 - 6000 Fax Number JV/A

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:
uIA N�A
N me E- ail Address
Li/A ill
Current Mailing Address C rent Street Address
utiA IJeA
Ci State Zip Cit State Zip
Telephone u/A - Fax Number u 1 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:
MIA u /A
N MI
of Registered Agent ' E- ail Address
ua NIA
C rent Mailing Address Cu rent Street Address
4/A if A
Cit State Zip City / State Zip
Telephone M/A Fax Number AI / 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.
L)n5t Li fl: D k ft)f Iz'Ict- i'o L- -h'� e r_ o Ehi\-&yyQuir
Type or pint name Title or Authority .
ato
Signature • Date
I, -J =r-. . • -a . k S , a Notary Public of the County of .._--\t \ry ©1i
State of North Carolina, hereby certify that ----‘c15¢.-� A 3?c \ __ 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 9 day of A���-cS� , 20 013
'^ttaiYtttEtUl,1R/11/e ,e'er>ys -
c.
I
r - _ Notary
Y o Seal of.
"ti; ij •?: My commission expires 3,/�45/ oc c
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