NCC222083_FRO Submitted_20220604

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
e v �% o A CA van p C- vL
2. Location of land -disturbing activity: City ork-ownship_VA40 A.-
�Q> Sh,�w�s1� pr��
Highway Street Latitude 35. 913 G I a Longitude — 79. 5 74 0 3q
3. Approximate date land -disturbing activity will commence: M0L9_Ck ZO Z l
4. Purpose of development (residential, commercial, industrial, institutional, etc.): C GytnwL,- ,r
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.5
6. Amount of fee enclosed: $ 0 6o a 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
8. Person to contact should erosion and sediment control issues arise during' land -disturbing activity:
Name RC'i) I l 1 $ O n E-mail Address r' t' k 1 � S01\® geV%_6Y-1 Ye �i.:-3 ,toy
Telephone l 9 ( & I - 4 -7 2-1 Cell # 9 101 Cc (0 - 91{ qFax # IJ f A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
0e_cAauk-tkfe,s Nc Prooer6�5, -LG
Name Telephone
Fax Number
1114 KAALe. 'R;.cev_ 9-d �llG I A%dale.
Current Mailing Address Current Street Address
&'1%ItAJ> a12ZO 'dal--tyuove- 7-2C)
City State Zip City State Zip
10. Deed Book No. 0 5 �oq "ot Page No. 0360
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):
t-2i4N.tc m`cEF✓a�.
Name
Current Mailing Pddress
City
Telephone
!w f -� Z t 1 'z
State Zip
Iti-3c)-�3
t= rA cNRY @ co,-,ti
E-mail Address
11t�_' N'\( C)QJ 'E Ri ve 1ZcJ
Current Street Address
City State Zip
Fax Number 3L Z- ?, -{ (a - U ZS 6

(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
1 -G 6 %-- �-- � S 6� �-_ t s
Name E-mail Address
—1 G S W-1 P,.J V_\_3 a- I) q. t V! -
Current Mailing Address Current Street Address
LTY-VL INJ 1 J C_
City State Zip
City
Telephone "I 12 - (o (e f — 4 1 ?_ h Fax Number,
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:
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.
o C� �2�r L �t s b,r 0 (� �R_�,�1 0\"3
iT e or print name Title or Authority
1.. Z ! S zv Z
Signature Date
a� ��- , a Notary Public of the County olf Jr '-�_
State of North Carolina, hereby certify than T_A Cty� 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
S. KELLY JOHNSON
Notary Public
Johnston Co., North Carolina
AA%(�frnission Expires July 03, 2021
day o20 20
Notary
My commission expires 2-02—