NCC221776_FRO Submitted_20220509

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 Crossings #2 @ Flowers Plantation
2. Location of land -disturbing activity: City or Township Flowers Plantation
Highway/StreetJordan Narron Road (SR 1735) Latitude 35,65681 N Longitude-78.34371 W
3. Approximate date land -disturbing activity will commence: Fall 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including oft -site borrow and waste areas): 36.99 Acres
6. Amount of fee enclosed: $ 7,175.00 . 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).
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:
Name Andrew Stocks Email Address astocks[ stocksengineerinci.com
Telephone [phone] Cell # 252-450-5140 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rebecca D. Flowers 800-343-0659 252-459-8197
Name Telephone Fax Number
4880 NC 42 East Same
Current Mailing Address Current Street Address
Clayton NC 27520
City State .,.,.. Zip
City
10. Deed Book No, 01789 Page No. 0784
Part B.
State Zip
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):
True Homes, LLC
Name
2649 Brekonridge Centre Dr. _
Current Mailing Address
Monroe NC 28110
City State Zip
iward [ truehomesusa.com
E-mail Address
Same
Current Street Address
City
State Zip
Telephone [phone] Fax Number 252-459-8196

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
Telephone
E-mail Address
Current Street Address
State Zip 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
State
E-mail Address
Current Street Address
Zip City State Zip
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.
Jon Ward
Type or print�ame
Signature '
-
--t_---------—----------------------------------------------
Director of Development
Title or Authority
Date
1,Y' i f1 Li�/� �S a Notary Public of the County of�C4
State of North Carolina, hereby certify that -Jon wont appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness rn ®I%N t d rarad�notarial seal,
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Notary
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