NCC216947_FRO Submitted_20211216

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
2
3
4
5
6
7
0
8
T J Auto Site Plan
Location of land -disturbing activity City or Township Town of Wilson's Mills
Highway/StreetSwift Creek Road Latitude 35.56010 Longitude-78.37620
Approximate date land -disturbing activity will commence: Upon Receipt of Permit
Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1. 12 aC
Amount of fee enclosed: $ 760.00 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ No ❑ Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity.
Name Tom Nelson E-mail [e-mail]
Telephone [phone] cell # NIA Fax # NIA
Landowner(s) of Record (attach accompanied page to list additional owners):
T J Auto, Inc. [phone] NIA
Name Telephone Fax Number
1302 Capital Blvd #A 1302 Capital Blvd #A
Current Mailing Address Current Street Address
Raleigh NC 27E0.1 Raleigh NC
City State
10. Deed Book No. 05854
Part B.
Zip City
Page No. 0365
State
27663
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):
T J Auto, Inc. [e-mail]
Name E-mail Address
1302 Capital Blvd #A 1302 Capital Blvd #A
Current Mailing Address
Raleigh NC
City State
Telephone [phone]
Current Street Address
Raleigh NC 27603
Zip City
Fax Number NIA
State
Zip

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:
NIA NIA
Name E-mail Address
NIA NIA
Current Mailing Address
NIA
City
Telephone NIA
Current Street Address
NIA
State Zip City
Fax Number NIA
State Zip
(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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City State Zip
Telephone NIA
���
E-mail Address
NIA
Current Street Address
NIA
City State Zip
Fax Number NIA
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 th information provided herein.
Thomas Nelson
Type print name Title or Authority
Signature
10/21 /21
Date
I, s f a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of 9>` 20
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