NCC216273_FRO Submitted_20211122

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 Clayton - Flowers Plantation Smithfield's Chicken 'N BAR-B-Q
2.
Location of land -disturbing activity: City or Township Wilders
Highway/Street NC HWY 42E Latitude 35.65213
Longitude -78.35261
3. Approximate date land -disturbing activity will commence: 10-01-2021
4.
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.2 acres
6. Amount of fee enclosed: $ 660.00 The application fee of $330.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $110 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:
9
10
Name Mark Beach
Telephone [phone]
E-mail Address [e-mail]
Cell # 919-921-0560
Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Southwest Crossroads Holdings, LLC
Name Telephone
4880 NC Highway 42 East 4880 NC Highway 42 East
Current Mailing Address Current Street Address
Clayton NC 27527
City State Zip
Deed Book No. 5794 Page No. 944
Clayton NC 27527
City
State
Fax Number
Zip
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):
Clayton Crossroads,LLC [e-mail]
Name E-mail Address
P.O. Box 979 1255 Crescent Greene Suite 105
Current Mailing Address Current Street Address
Cary, NC 27512 Cary, NC 27518
City State Zip City State Zip
Telephone [phone] 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
Current Mailing Address
City State Zip
Telephone.
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
Lew Starli
Sign
Member Manager
Title or Authority
Date
1, L 1-1- + ( 1 �k 1✓Zfi- '_� , a Notary Public of the County of
State of North Carolina, hereby certify that LazW (_� i�` // ,
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personally before me this day and being duly sworn acknow( tl�hat the above form was
executed by him.
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Witness my hand and notarial seal, this ,� U fib -day of � fi � , 20
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