NCC222056_FRO Submitted_20220603

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 Crescent Mills
2.
3.
4.
5,
6.
7.
Location of land -disturbing activity: City or Township Town of Wiilson's Mills
Highway[Street Strickland Road Latitude 35,57601 Longitude-78.38143
Approximate date land -disturbing activity will commence: May 01, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): _97acres
Amount of fee enclosed: $ 10,670.00 . 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).
Has an erosion and sediment control plan been filed? Yes X No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Raymond Rinker E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
Landowner(s) of Record (attach accompanied page to list additional owners): (SEE ATTACHED)
Greenfield CM Holdings, LLC 919-630-6641
Name Telephone Fax Number
9601 Six Forks Road Suite 270
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
10. Deed Book No. 6015 709-712 Page No. 962-966
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):
Ashton Raleigh Residential, LLC [e-mail]
Name E-mail Address
900 Ridgefield Suite 335
Current Mailing Address Current Street Address
Raleigh NC 27609
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:
Current Mailing Address
city State
Telephone.
E-mail Address
Current Street Address
Zip city state Zip
Fax Number
(b) It 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 State
Telephone,
E-mail Address
Current Street Address
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.
A-1
Type or print name Title or Authority
_Z
9 ure Date
------------------- — ----------------------------- — ------------ — ------ — -- — ------------- — --------------------- — — ----------
1, &N a Notary Public of the County of
State of North Carolina, hereby certify that Le*'Ul� appeared
personally before me this day and being duly sworn a6knowledged thdt the above for was executed
by him.
Witness my hand and notarial seal., this day of 20
MARY HILL HEROLD
NOTARY PUBLIC Nota
My MA E COUNTY, N.C.
ission Expires 9-24-2026. My Comm
I
expires

SUPPLEMENTAL LANDOWNER OF RECORD INFORMATION (
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name
Current Mailing Address
City
Telephone Fax Number
Current Street Address
state Zip City
10. Deed Book No. Page No.
State
on.