NCC240599_FRO Submitted_20240304

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: Archer Pointe
2. Location of land-disturbing activity: County: Johnston City or Township: Meadow
Highway/Street: SR 1111 Latitude: 35.3066 Longitude: -78.4946
3. Approximate date land-disturbing activity will commence: January 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.9 acres
6. Amount of fee enclosed: $ 1,200 _ The application fee of$400.00 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).
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: Sam Wilkins E-mail Address: samuelpwilkins(caol.com
Telephone: (919) Cell: [phone] Fax: (919)
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Samuel Wilkins [phone] (919)
Name Telephone Fax
901 Marler Pond 901 Marler Road
Current Mailing Address Current Street Address
Benson NC 27504 Benson NC 27504
City State Zip City State Zip
10. Deed Book No.: 5924 Page No.: 8— 10 Provide a copy of the most current deed.
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):
Samuel Wilkins samuelpwilkins(c aol.com
Name E-mail Address
901 Marler Road 901 Marler Road
Current Mailing Address Current Street Address
Benson NC 27504 Benson NC 27504
City State Zip City State Zip
Telephone: [phone] Fax (919)

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 (919) Fax Number (919)
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.
Samuel Wilkins Owner
Type or print name Title or Authority
(//
4, 2 6 - 2-7
Signature Date
I, O r r i r A-1--ca(Ct , a Notary Public of the County of LA) ncto
State of North Carolina, hereby certify that 60t, l}e/i \AI I p' 'f appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
��th
day
tJM O h(,1 , 2023
Witness my hand and notarial seal, this y of
Jennifer Afford Q �i/U ,-AloaLg
f
C„ r ' NOTARY PUBLIC a
eal Johnston County,NC p,�
My Common Expires December 15,2024 My commission expires D(J✓. 15 , 2.4