NCC233477_FRO Submitted_20231127

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 Brickstone Subdivision - Lots 7, 8, & 9
2. Location of land-disturbing activity: City or Township Banner
SR 1168 35.4226 -78.5452
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence: 11-01-2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .4 acres (3 lots)
6. Amount of fee enclosed: $ 300.00 ($100/lot) . 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Pamela Jane Gay E-mail Address [e-mail]
Telephone [phone] Cell# 910-237-0572 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Caviness Land Development, Inc. - -
p 910 339 6330
Name Telephone Fax Number
1041 B Robeson St. 1041 B Robeson St.
Current Mailing Address Current Street Address
Fayetteville, NC 28305 Fayetteville, NC 28305
City State Zip City State Zip
10. Deed Book No. 6194 Page No. 579
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):
Caviness Land Development, Inc. [e-mail]
Name E-mail Address
1041 B Robeson St. 1041 B Robeson St.
Current Mailing Address Current Street Address
Fayetteville, NC 28305 Fayetteville, NC 28305
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.
Pamela Jane Gay CEO
Type or print name Title or Authority
61.77146“: "Nalgae io -13-03
Signature Date
I, Cynz'f\ L , a Notary Public of the County of C,umb¢.c land
State of North Carolina, hereby certify that?�P( \ 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 . day of p pbe-C , 20 23
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v OTAR ;< ; Notary
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