NCC215584_FRO Submitted_20211008

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
Land Quality Section, N.C. Department of Environment and Natural Resources. (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.
Project Name Johnston County Reedy Branch WWPS & FM
2. Location of land -disturbing activity: County Johnston City or Township Smithfield
Highway/Street Varies — See Location Map Latitude 35°33'1" N Longitude 78'23'16" W (PS Site)
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): N/A
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16.9 AC
6. Amount of fee enclosed: $1,235. The application fee of $65.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chandra Cox Farmer, P.E. E-mail Address chandra.farmerd_)Oohnstonnc,com
Telephone [phone] Cell # Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Public Roads and RAN & Easements
Name
Current Mailing Address
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
10. Deed Book No. fN/Al Page No. [N/AL Provide a copy of the most current deed.
Part B.
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):
Johnston County
Name
P.O. Box 1049
Current Mailing Address
Smithfield NC 27577
City State Zip
Telephone [phone]
rick.hester(cDiohnstonnc.com
E-mail Address
207 E. Johnston Street, Courthouse — B - 206
Current Street Address
Smithfield NC 27577
City State Zip
Fax Number [phone]

(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 firm
the authority to execute instruments for the Financially Responsible Person). I agre `�rovi
corrected information should there be any change in the information provided herein. y�
Rick Hester County Manager
T tint name/ Title or Authority17
CA
Sig ature Date -1
o u cQarcQ a Notary Public of the County of
State of North Carolina, hereby certify that �� vQ . �-i c s-Ilrer 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 � b day of q-, , 20 a I
W O �O p��0i
Notary
Seal a
Z = My commission expires t y •
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