NCC242566_FRO Submitted_20240822

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 Lot 40 Laurer Ridge Lots 1,2,3 Laurer Ridge Front Lots
2. Location of land-disturbing activity: City or Township Welders
Highway/Street Maggie Way Latitude 35.73646 Longitude -78.38258
3. Approximate date land-disturbing activity will commence: July 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.954 acres
6. Amount of fee enclosed: $ $400.00 . The application fee of$450.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $225 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 Scott Weingartner E-mail Address [e-mail]
Telephone Cell# 919-669-0399 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Southview Homes, LLC 919-422-9707
Name Telephone Fax Number
PO Box 9 200 US 70 Hwy
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
10. Deed Book No. 99 Page No. 335 and Deed Book No. 100 Page No, 160
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):
Southview Homes, LLC [e-mail]
Name E-mail Address
PO Box 9 200 US 70 Hwy
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
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:
Adam Kingsley [e-mail]
Name E-mail Address
PO Box 9 200 US 70 Hwy
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
Telephone [phone] 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:
Adam Kingsley [e-mail]
Name of Registered Agent E-mail Address
PO Box 9 200 US 70 Hwy
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
Telephone [phone] 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.
Adam Kingsley Member
Type or pr t name Title or Authority
7isi2024
Sign 6L)/(7-- Date
I, S1/4\-trt \ L - (1.,,pQ,Ds , a Notary Public of the County of
State of North Carolina, hereby certify that AAavvx Kin %Sl,.0---"1 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 61 day of ,J :-) `/ , 20 24
SHERRY L. EDWARDS
NOTARY PUBLIC Notary
JOHNSTO�1 UNTY
tily Commisstdt'r kpi N.0
pnes 4-5-2028..
My commission expires