NCC243200_FRO Submitted_20241018

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 CnsooentMi||s— CD Package#3
2. Location of land-disturbing activity: City orTownship Town ofVWlson'uMills
Highway/Street Strickland Road Latitude 35.57601 Longitude '78.38143
3. Approximate date land-disturbing activity will commence: PWoy2O24
4. Purpose of development(residential,commercial, industrial, institutional,etc.): residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste oreom): 33.00
G Amount of fee enclosed: $ 6.875.00 . The application fee of$4OO.00 per acre(rounded upto the next
acre) is assessed for the first 10 acres and an additional$125 per acre for each additional acre(rounded
upto the next auns).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Nome Chris Hamrick E-mail Address Chrio.hannriuh@star|ighthonnea.oum
Telephone [phone] C*||# Fox#
8. Landowner(s) of Record (attach accompanied page to list additional owners): (SEE ATTACHED)
GG Crescent Mills Limited Partnership
Name Telephone Fax Number
351 King 8TE- 13t» Floor
Current Mailing Address Current Street Address
Toronto Ontario, Canada K85AOL8
City State Zip City State Zip
10. Deed Book No. O6538 Page No. O482
Part B.
1. Person(s) or firm(a) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties onan attached oheuU:
Ashton Ra|eiqh Residenba|, LLC Chris.homriok(d,)a[ar|ighthomou.onm
Name E-mail Address
SOORidqefia/d Dr, Suite 335
Current Mailing Address Current Street Address
Raleigh NC 27809
City State Zip city 8baba Zip

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.
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Type or print name Title or Authority
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Signature Date
I, (ILI/AAA rA1--- , a Notary Public of the County of
/ ,...l
State of North Carolina, hereby certify that (,,v‘t i s 1-jc..evipia 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 2-0 day of /1/14-f`rA-... , 20 21
Raymniii Rinker
NOM491PUBLIC
Wake County
North Carolina
My Commission Expires August 3,2025
Notary
My commission expires it 3/

SUPPLEMENTAL LANDOWNER OF RECORD INFORMATION (
8. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
city State Zip City State Zip
10. Deed Book No. Page No.