NCC240652_FRO Submitted_20240326

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 Land Quality Section,
N.C. Department of Environment and Natural Resources. (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 Hocutt Place Subdivision
2. Location of land-disturbing activity: County Johnston City or Township O'Neals
Highway/Street Richardson Rd Latitude 35.762321° N Longitude -78.277900° W
3. Approximate date land-disturbing activity will commence: Spring 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.45 Acres
6. Amount of fee enclosed: $ 1,520 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ethan Averette E-mail Address eaverette ci.stocksengineering.com
Telephone [phone] Cell # 919-725-4213 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Virginia Hocutt Hasal N/A
Name Telephone Fax Number
142 Eatmon Rd 142 Eatmon Rd
Current Mailing Address Current Street Address
Zebulon NC 27597 Zebulon NC 27597
City State Zip City State Zip
10. Deed Book No. 05518 Page No. 0539 (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):
Hocutt Place, LLC humphreysolutionsllcagmail.com
Name E-mail Address
216USHwy70W 216USHwy70W
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
Telephone [phone] Fax Number N/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:
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:
Joey Humphrey humphreysolutionslIc(cr�gmail.com
Name E-mail Address
2. 9os— SabNc.resf V11h�.e 4� .
Current Mailing Address Current Street Address
120, I,4. 4 N_6, 27t I
City State Zip City State Zip
G� G
Telephone /1 / 2141 10 Z 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.
/#.e(.41,4/1_
Type or pr. namep7 ,,,,.e7
Title or Athority
v I Z - l / - z 3
Signat Date
I, 7. M istihael Sides , a Notary Public of the County of IV QSLi ,
State of North Carolina , hereby certify that "'Joey glibi Okf-ty
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 ( q day of DvL , 2023.
J. MICHAEL STOCKS 'U�a
Notary Public Not ry
Seal North Carolina
Nash County My commission expires f/ZI Z S