NCC233263_FRO Submitted_20231101

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 Graham's Place Phase 1
2. Location of land-disturbing activity: City or Township Boon Hill
Highway/Street Princeton Kenly Road Latitude 35.49907 Longitude-78.13621
3. Approximate date land-disturbing activity will commence: September 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.67
2,8OO.00 The application fee of F389per acre (rounded
6. Amount of fee enclosed: $ pp�
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 I
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Larry Anderson E-mail Address [e-mail]
Telephone Cell# 919-902-0335 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Miland, Inc. 919-902-0335
Name Telephone Fax Number
106 Britt Street 106 Britt Street
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
10. Deed Book No. 6205 Page No. 395-396
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):
Miland, Inc. [e-mail]
Name E-mail Address
106 Britt Street 106 Britt Street
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
Telephone [phone] 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Larry Anderson President
r pr��Pt n.� of Title or Authority
8-25-2023
Sig ture Date
Steven S. Sanderson , a Notary Public of the County of Johnston
State of North Carolina, hereby certify that Larry Anderson 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 25 day of AU USt 202023
Steven S. Sanderson Notary
ivy Public
WW1'County, N s•0 11-3-2027
Commission Ex fires • My commission expires