NCC222637_FRO Submitted_20220725

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.
2.
3.
4.
5.
6.
7
Project Name Gregory Ridge
Location of land -disturbing activity: City or Township
Elevation
Highway/Street SR 1335 Latitude 35.5012 Longitude
A roximate date land -disturbing activity will commence:
05-01-2022
-78.5110
pp
Purpose of development (residential, commercial, industrial, institutional, etc.): residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.5
Amount of fee enclosed: $ 2,280.00 . 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__
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Bradley Stancil E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Stancil Builders, Inc. [phone] [phone]
Name Telephone Fax Number
466 Stancil Rd. 466 Stancil Rd.
Current Mailing Address Current Street Address
Angier NC 27501 Angier NC 27501
City State Zip City State Zip
10. Deed Book No. 5880 Page No. 769
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):
Stancil Builders, Inc. [e-mail]
Name E-mail Address
466 Stancil Rd. 466 Stancil Rd.
Current Mailing Address Current Street Address
Angier NC 27501 Angier NC 27501
City State Zip City State Zip
Telephone [phone] Fax Number [phone]

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
City
Telephone
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 State Zip
Telephone
E-mail Address
Current Street Address
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.
Bradley Stancil
Type or rint name
Sig ure
Vice President
Title or Authority
Date
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a Notary Public of the County of L✓,4ke-
State of North Carolina, hereby certify that U/Ai^c� , 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 17day of /-z20_
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