NCC241612_FRO Submitted_20240528

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 Stone Creek
2. Location of land-disturbing activity: City or Township . Clayton
Highway/Street_Tenacious Way Latitude 35.599326 Longitude-78.418303
3. Approximate date land-disturbing activity will commence:_05/27/2024 or when approved
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): . 2 t 10
6. Amount of fee enclosed: $_1,000 . 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). Individual residential lots plans are$100 per lot.
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 Patrick Busse E-mail Address_patrick.bussehabitatwake.org
Telephone Cell# 919-793-6633 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Habitat for Humanity of Wake County/Patricia Burch 919-833-1999
Name Telephone Fax Number
2420 N. Raleigh Blvd. 2420 N. Raleigh Blvd.
Current Mailing Address Current Street Address
Raleigh NC 27604 Raleigh NC 27604
City State Zip City State Zip
10. Deed Book No. 06134 Page No. 0678
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):
Habitat for Humanity of Wake County/ Patricia Burch_patricia.burch(a�habitatwake.org
Name E-mail Address
2420 N. Raleigh Blvd. 2420 N. Raleigh Blvd.
Current Mailing Address Current Street Address
Raleigh NC 27604 Raleigh NC 27604
City State Zip City State Zip
Telephone_ 919-833-1999 Fax Number

2. (a) If the Financially Responsible Party is not u resident of North Coroino, give mama 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 m Partnership or other person engaging in business under an
assumed namo, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party ium Corporation, give name and street address of the Registered Agent
Habitat for Humanity-Patricia Burch Patricia.bunch(cDhabitotwakouvq
Name of Registered Agent E-mail Address
2420 N. Ra|niqh Blvd. 2420 N. Ra|eiqh Blvd.
Current Mailing Address Current Street Address
Roieiqh NC 27804 Ro|oiqh NC 27604
City State Zip _City State Zip
Telephone 910'8334999 Fax Number
The above information is true and correct to the best ofnmy 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 oftorney'in'hact, or if not an indiv|dua|, by an offioar, dinoctor, pudnar, or registered agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there be any change in the information provided herein.
Patricia Burch CEO
,Iype or print name Title or Authority
05/08/2024
Signature Dmbs
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[ �\�6^*, i�(�J V�Y)r\`\k�[�T \ . o Notary Public of the County of
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State of North Com|ina, hereby certify that
appeared personally before me this day and being duly ovvomn acknowledged that the above
form was executed bvhim. �
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