NCC215300_FRO Submitted_20210927

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name.
l+
3
4
American Leadership Academy
Location of land -disturbing activity: County.
Highway/Street 3770 US Hwy 70 Bus.
City or Township Clayton
de 35.562085' Longitude -78.3877350
Approximate date land -disturbing activity will commence: October 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): institutional (school)
Johnston
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
30.5 ac
6. Amount of fee enclosed: $ 2,015.00 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
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 Jim Way E-mail Address [e-mail]
Telephone [phone]
Cell # n/a
Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stephen Howard Gower & Susan Alexander Gower
910-988-0617 n/a
Name
Telephone Fax Number
1707 Windsor Road
n/a
Current Mailing Address
Current Street Address
Kinston, North Carolina 28504
n/a
City State Zip
City State Zip
10. Deed Book No. 1 135 Page No.
382-384 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.
Johnston CD, LLC
[e-mail]
Name
E-mail Address
3115 East Lion Lane, Suite 300
n/a
Current Mailing Address
Current Street Address
Salt Lake City, Utah 84121
n/a
City State Zip
City State Zip

Telephone [phone] Fax Number nla
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:
Jim Way [e-mail]
Name E-mail Address
10320 Durant Road, Suite 101 nla
Current Mailing Address Current Street Address
Raleigh, North Carolina 27614 nla
City
Telephone
State Zip City State Zip
702-528-1514 Fax Number n1a
(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:
nla
nla
Name of Registered Agent
E-mail Address
nla
nla
Current Mailing Address
Current Street Address
nla
nla
City State Zip
City State Zip
n/a
nla
Telephone
Fax Number
(c) In order to facilitate Express Permitting, it
is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Little Diversified Architectural Consulting
[e-mail]
Engineering Firm or other consultant
E-mail Address
David Powlen, RLA
704.561.3472 nla
Individual contact person (type or print)
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.
SC C14f 0 wv� ely- ZM a vt a�
e or print n me Title or Auth rity
Signature Date
w i lSon , a Notary Public of the County of lyQ
State of Plo#�-i- r a iereby certify that r6 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 �i I day of U _ 20
1"
®R.
JACQUELINE WILSON
Notary Pubdc - State of Utah
Comm, No,
Expire10578
My Commission Expires on
Feb 14, 2024