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HomeMy WebLinkAboutNCC215563_FRO Submitted_20211007JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NameWilson's Walk 2. Location of land -disturbing activity: City or TownshipWllson Mills Highway/Street Latitude Longitude Cole Road 35.5882145-78.42222288 3. Approximate date land -disturbing activity will commence:10/15/2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.); Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):62 6. Amount of fee enclosed: $already paid The application fee of $380.00 per acre (rounded up to the next acre) is assessed for the first 10 acres and an additional $125 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 Fv] No ❑ Enclosed_ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Raymond Rinker E-mail Addressraymond.rinker@ashtonwoods.com Telephone919-229-3238 cell # 919-229-3238 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Starlight Homes North Carolina LLC Name Telephone Fax Number 5711 Six Forks Road Ste 300 5711 Six Forks Road ste 300 Current Mailing Address Current Street Address Raleigh NC 27609 Raleigh NC 27609 City State Zip City State Zip 10. Deed Book No.5127 Page No.590 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): Raymond Rinker Raymond.rinker@ashtonwoods.com Name E-mail Address 5711 Six Forks Rd ste 300 5711 Six Forks Rd ste 300 Current Mailing Address Current Street Address Raleigh NC 27609 Raleigh NC 27609 City State Zip City State Zip Telephone919-232-5100 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephon 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. Raymond Rinker Vice President of Land Development 6� Type or print na Title or Authority t, _ 1015/2021 Signatu e Date -----------------------------------------------------------------.------------------------------------------------------------------ I, , a Notary Mary Herold y Wake Public of the Count of State of North Carolina, hereby certify that Raymond Rinker 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 5 day of OCr �, 2021 MARY HILL HEROLD NOTARY PUBLIC Notary WAKE@QUNTY, N.C. ✓ �/ l FCommission Expires 9-24-2026. My commission @xpireS" "' �v