NCC223005_FRO Submitted_20220907

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 Environmental Quality. (Please type or print and, if the question is
not applicable or the e-mail andlor fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name PINECROFT
2. Location of land -disturbing activity: County JOHNSTON City or Township PRINCETON
Highway/Street PEARCE STREET Latitude 35.462513 Longitude-78.156000
3_ Approximate date land -disturbing activity will commence: JUNE 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.509 AC
$65 FOR ONE ADDITIONAL ACRE.
6. Amount of fee enclosed: $$975 PREVIOUSLY PAID . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
REVISION
7. Has an erosion and sediment control plan been fled? Yes X No Enclosed ENCLOSED
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name STACY JOHNSON E-mail Address [e-mail]
Telephone Cell # 919-921-2642 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J AND N DEVELOPERS LLC
919-921-2642
Name
Telephone Fax Number
PO BOX 658
501 S PEARL STREET
Current Mailing Address
Current Street Address
PRINCETON NC 27569
PRINCETON NC 27569
City State Zip
City State Zip
10. Deed Book No. 4 8 81 Page No.
5 5 0 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties
on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
J AND N DEVELOPERS, LLC
[e-mail]
Name
E-mail Address
PO BOX 658
501 S PEARL STREET
Current Mailing Address
Current Street Address
PRINCETON NC 27569
PRINCETON NC 27569
City State Zip.
City State Zip
Telephone q l q-q 2_1 `1C04 Z
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:
Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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
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.
STACY JOHNSON
Type or print name
Signature
me w1ke-r Ze!L4 ce
Title or Autho Ety
"S-�/ 91aOz Z _
Date'
I, C-D V0 t joy1fiso() __., a Notary Public of the County of LbWv)
State of North Carolina, hereby certify that �C khnson appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness my, OtdIj15tarial seal, this l
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"�'pTARy' -
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day of , 20
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Notary
My commission expires