NCC242967_FRO Submitted_20241002

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 Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (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. Beaverdam Creek Rehabilitation
1. Project Name
2. Location of land-disturbing activity: CountyJohnSton City or Township Princeton
Highway/Street Pine View St Latitude 35.46092 Longitude -78.15394
3. Approximate date land-disturbing activity will commence: 7/1/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Maintenance
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.2
6. Amount of fee enclosed: $ 200 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
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 Luke Baker - TRC Engineers E-mail Address [e-mail]
Telephone [phone] Cell# 910.723.5158 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Town of Princeton 919-936-2842
Name Telephone Fax Number
PO Box 67 503 Dr Donnie H Jr Blvd West
Current Mailing Address Current Street Address
Princeton NC 27569 Princeton NC 27569
City State Zip City State Zip
10. Deed Book No. 02630 Page No. 0108 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Town of Princeton [e-mail]
Name E-mail Address
PO Box 67 503 Dr Donnie H Jr Blvd West
Current Mailing Address Current Street Address
Princeton NC 27569 Princeton NC 27569
City State Zip City State Zip
Telephone [phone] Fax Number

Landowner(s) of Record (attach accompanied page to list additional owners):
J&N Developers LLC
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. 04881 Page No. 0550 Provide a copy of the most current deed.
Landowner(s)of Record (attach accompanied page to list additional owners):
Ronald and Paula Waters
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. 03573 Page No. 0747 Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
William Ormond and Ginger Massengill
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book NQ.,01495 Page No. 0957 Provide a copy of the most current deed.

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.
Michael King Town Administrator
Type or pri t an Title or Authority
U 05/20/2024
Signature Date
I, April Williamson, a Notary Public of the County of Johnston
- - t)
State of North Carolina, hereby certify that �►l1Lt /� L 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 20th day of May , 2024_
rrrrrrrrllrlur►Irylll4 !_. .� �WIL ! -. N44.
� -443 TAR ,,02'Y My commission expires .5 -/

•
•
•
•
•
• 1'