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HomeMy WebLinkAboutNCC241516_FRO Submitted_20240517 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 Hillard Lane 2. Location of land-disturbing activity: City or Township Wilders Highway/Street Hillard Lane Latitude 35.739111 Longitude Hillard Lane 3. Approximate date land-disturbing activity will commence:Spring/Summer 2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.7 ac 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 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 Wayne Baker E-mail Address waynebaker911@gmail.com Telephone 919-422-2753 Cell# Fax# 9. Landowner(s)of Record (attach accompanied page to list additional owners): Tupelo Honey Land Development, LLC 919-422-2753 Name Telephone Fax Number 149 S Bloodworth St Same Current Mailing Address Current Street Address Raleigh NC 27601 Same City State Zip City State Zip 10. Deed Book No. 06450 Page No. 0007 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): Tupelo Honey Land Development, LLC 919-422-2753 Name E-mail Address 65 Glen Road. Suite 122 Same Current Mailing Address Current Street Address Raleigh NC 27529 Same City State Zip City State Zip Telephone 919-422-2753 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: Tupelo Honey Land Development, LLC 919-422-2753 Name of Registered Agent E-mail Address 65 Glen Road, Suite 122 Same Current Mailing Address Current Street Address Raleigh NC 27529 Same City State Zip City State Zip Telephone 919-422-2753 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. Wet yner E�elke ,4 4.e tit &AZ Al ,v4e t, 2 Type or print name Title or Authority Ai{/ 'L A-U9 u b-r 114 13 0 Z Signature Date I. - Jfi1(J 1f1 o} V , a Notary Public of the County of JOW3St0k) State of North Carolina, hereby certify that I\\ B t`— appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. , ) Witness my hand and notarial s I this day of vJ , 20 4% % "\• o ar'y Seal - PUBOC • (�5 2,3 zoze ;te '• ;��; commission expires ,,,•5 SON. ......O ``,`