NCC215552_FRO Submitted_20211007

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 NIA in the blank.)
Part A.
1. Project Name Olivia Preserve
2. Location of land -disturbing activity: City or Township Johnston Coun
Highway/Street NC HWY 96 Latitude 35.654555N Longitude = 78.280659 W
3. Approximate date land -disturbing activity will commence: Summer 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.57 Ac.
6. Amount of fee enclosed: $ 600.00 . The application fee of $300.00 per acre (rounded up to the next
acre) is assessed for the first 10 acres and an additional $100 per acre for each additional acre
(rounded up to the next acre).
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 Kevin Varnell E-mail Address kvarnellCaD-stocksengineering.com
Telephone [phone] Cell # 252-382-0012 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Randy L. & Rhonda B. Edwards
Name
2505 Wendell Road
Current Mailing Address
Wendell NC 27591
City State Zip
10. Deed Book No. 03918
Part B.
252-459-8196 N/A
Telephone Fax Number
Same
Current Street Address
Same
City State Zip
Page No. 0664
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):
River Wild, LLC
Name
114 W. Main Street
Current Mailing Address
Clayton NC 27520
City State Zip
David (&theriverwildteam.co m
E-mail Address
Same
Current Street Address
Same
City State Zip
Telephone 91IM97-1101 Fax Number,

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give dame 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.
Reid Smith
Type or print name Title or Authority
/11/� '44— — S I
2�
S' nature Date
I, �(�tf , a Notary Public of the County of _10
State of North Carolina, hereby certify that aid'j'W-+t11
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 �O day o 20_21
`4 NpTAR T4 I
Seal
PUBLIC My commission expires --
v