NCC242413_FRO Submitted_20240815

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 CRAu41A PoA/D &4A TACT — F 1ASEd I
2. Location of land-disturbing activity: City or Township PLE4SAIJT CW YE- ToWAJ5rliP
Highway/Street BRUM aye Ate Latitude 55.5057 Longitude - 76.5086
3. Approximate date land-disturbing activity will commence: Uitui ItE,CEoPr eF PfeM>T.
4. Purpose of development (residential, commercial, industrial, institutional, etc.): IESIe BTisfL_
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10.(07
Mora, : FEE
6. Amount of fee enclosed : PREwousLY PASS . 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 ✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name LAMAI° eL.OFroil E-mail Address Iannycla nbuilder- .0.grrai cnrn
Telephone (919) 97/- 5353 Cell # (9/9) 97/- 5353 Fax# (919) 934- 31DO
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Ca14AI1A11 L'o41b Z,AL— L.OAI brA/EloPAIE•tlr, L.L.G. (919) 97/- 5353 (919) 934- 3/00
Name elephone Fax Number
Z70/ FoLEA/TA >fZoA N 27O/ PaLFAIr4 E'Ab
Current Mailing Address Current Street Address
CLA11roA0 WC' 27520 &AYo cl .(!,G 275Zo
City State Zip City State Zip
10. Deed Book No. 04546 Page No. 0704
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):
CIZAAlbi alb t4A — LAA/ 1JEVELOPA4cl/T1 L.L.G. lannyclillonbuilder cJ jmai/.tarn
Name E-mail Address
270/ Pos ilrA PoAb 270/ PPLErITA Rego
Current Mailing Address Current Street Address
Ca a/'roAi AIC. 2752o CLIP/oil 27520
City State Zip City State Zip
Telephone (9/9) 97/- 5353 Fax Number (919) 934- 3/00

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:
AllA A14A
N me E- ail Address 1
N/A N/A
C rrent Mailing Address Current Street Address
u/A u/A
Ci y State Zip Ci y State Zip
Telephone NVA Fax Number N/A
(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:
IA u /A
me of Registered Agent E-(nail Address
N/A uiA
Crent Mailing Address C rent Street Address
i1/41lA tJ /A
Cif{y State Zip Ci y State Zip
Telephone N/A Fax Number N/A 1
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.
LAWN K.CLIF 0AI 14E.mtsEx NIAWAGEK
Type or i t name Title or Authority
?- / - -
gnature Date
I, �Ati\t,. 'Ri h. nil CITIS , a Notary Public of the County of 'tniC)r1
State of-Noll arolina, hereby certify that Lilo K . C i appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. `
Witness my hand and„gQElrial seal, this 1 day of �� <�U� , 20 - I,
,`'..,.\,c WAT/rj,.
1 S IA Vi. 2\`\.0.6\ Li3r-Stil)(AIJ nCir-v
o .2:1_ rs
72 Notary
1 =•.,GB +,.�' My commission expires l \ \ 1 DCY (.0
,,,,, ,•••...,..1 C , ,
s.e.

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
2. Location of land-disturbing activity: City or Township
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $ . 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
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name E-mail Address
Telephone Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
5TEEL BRIDGE. CRass»W& 1 L.L.C. (919) 97l-5353 (919) 914 -51on_
Name elephone Fax Number
5160 PVC 1l,Grn%4y 42 1✓Esr 5/4.6 JUG i,Gs1wAy 42 WEsr
Current Mailing Address Current Street Address
&ARAMEJ_ A!G 27529 G4Rd1E.R NG 27529
City State Zip City State Zip
10. Deed Book No. 06375 Page No. os67
P4{t.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):
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number

6/12/24
Steel Bridge Crossing, LLC, landowner, gives Graham Pond Road-Lan Development, LLC permission to
obtain all permits and conduct land disturbing activities on their property.
Lanny K Clifton
Steel Bridge Crossing, LLC
Registered Agent
Lanny K Clifton
Graham Pond Road-Lan Develop , LLC
Registered Agent