NCC243106_FRO Submitted_20241009

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 Black Creek Farms
2. Location of land-disturbing activity: City or Township Town of Angier
Plainview Church
Highway/Street Rd Latitude_35.51 Longitude -78.66
3. Approximate date land-disturbing activity will commence:_10/4/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):_45 ac.
(Previously Paid $9,250)
6. Amount of fee enclosed: $$12,375 . 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_X _No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Thurm Bowen E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pulte Home Company, LLC 919-816-1161
Name Telephone Fax Number
1225 Crescent Green Dr, Ste 250 1225 Crescent Green Dr, Ste 250
Current Mailing Address Current Street Address
Cary, NC 27518 Cary, NC 27518
City State Zip City State Zip
10. Deed Book No. 6749 Page No. 508-514
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):
Pulte Home Company, LLC [e-mail]
Name E-mail Address
1225 Crescent Green Dr, Ste 250 1225 Crescent Green Dr, Ste 250
Current Mailing Address Current Street Address
Cary, NC 27518 Cary, NC 27518
City State Zip City State Zip
Telephone_919-816-1161 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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Ste 550 2626 Glenwood Ave, Ste 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 _ Raleigh, NC 27608
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.
Chris Raughley Vice President of Land Development
Type or print name Title or Authority
L to • 'Z - Zd!-
Signature Date
I, 5 th-Cehorir W 'Urns , a Notary Public of the County of 1�uf1�a m
State of North Carolina, hereby certify that C/h✓t 'U�h appeared
personally before me this day and being duly sworn acknowledged th the above form was
executed by him.
Witness my hand and notarial seal, this 1 day of a:AD kY , 20 2-1-4
NotarySeal SARAH-CATHERINE W BURNS i
Notary Public, North Carolina My commission expires uV J 21 ,2_026
Durham County
My Commission Expires
July 27,2028