NCC220732_FRO Submitted_20220211

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 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.
1. Project Name Antioch Church Road Subdivision
2. Location of land -disturbing activity: County Johnston City or Township O'Neals
Highway/Street Antioch Church Rd Latitude 35.69067' N Longitude-78.2595150
3. Approximate date land -disturbing activity will commence: Winter 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.58 Acres
6. Amount of fee enclosed: $ 2,970 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ethan Averette E-mail Address eaverette(o),stocksengineering.com
Telephone [phone] Cell # 919-725-4213 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
RRT Development LLC 919-302-4906 N/A
Name Telephone Fax Number
PO Box 190 5215 Hwy 70 Bus
Current Mailing Address Current Street Address
Clayton NC 27528 Clayton NC 27520
City State Zip City State Zip
10. Deed Book No. 05917 Page No. 0452 (Provide a copy of the most current deed.)
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):
John H Richard
Name
PO Box 190
Current Mailing Address
Clayton NC 27528
City State Zip
Telephone [phone]
hank(ocarolinacomfortair.com
E-mail Address
5215 Hwy 70 Bus
Current Street Address
Clayton NC 27520
City State Zip
Fax Number N/A

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
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 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.
John H. Richard Owner
Type or print name Title or Authority
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SibKaiure Date
1, CW WRI'!�ht a Notary Public of the County of /I�s� OU c
State of North Carolina hereby certify that D "'JA /Z
appeared personally before me this day and being duly sworn acknowledged that the above
form wpVmepg�ed by him.
W M my hanh d notarial seal, this day of 021.
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Sear L I C Notary
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