NCC241175_FRO Submitted_20240418

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 BEVERLY SUBDIVISION PHASE 2
2. Location of land-disturbing activity: City or Township FOUR OAKS, JOHNSTON COUNTY
Highway/Street REEDY CREEK RD Latitude 35.49407 Longitude -78.51832
3. Approximate date land-disturbing activity will commence: SUMMER 2020
4. Purpose of development(residential, commercial, industrial,institutional,etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 38.85
PREVIOUSLY PAID $3,000
6. Amount of fee enclosed: $ $2,900 . The application fee of$300.00 per acre(rounded
up to the next acre) is assessed for the first 10 acres and an additional $100 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 JEFF WHITE E-mail Address [e-mail]
Telephone [phone] Cell# 919-422-5741 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
GHD-BEVERLY, LLC
Name Telephone Fax Number
1330 SUNDAY DR. STE 105
Current Mailing Address Current Street Address
RALEIGH NC 27604
City State Zip City State Zip
10. Deed Book No. 05694 Page No. 0466
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):
JEFF WHITE [e-mail]
Name E-mail Address
1330 SUNDAY DRIVE, SUITE 105 1330 SUNDAY DRIVE, SUITE 105
Current Mailing Address Current Street Address
RALEIGH NC 27607 RALEIGH NC 27607
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.
Ty• - r print n or
Title or Authority
9. 22 2
Sig y; e Date
I, C2Yvi-e L_0,- i c S , a Notary Public of the County of VVA, -
State of North Carolina, hereby certify that ,,e.W(d.1 ��(►��,�� appeared
personally before me this day and being duly swcm acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 2- day of 1 h'\b v , 20 a.O%
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My Comm.Exp. My commission expires )'I l t1 I u
02-19-2025
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