NCC223825_FRO Submitted_20221122

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
2.
3,
Project Name Parkview Center
Location of land -disturbing activity: City or Township Cleveland
Highway/Street SR 1010 Latitude 35.56803
Approximate date land -disturbing activity will commence: ASAP
Longitude -78.53156
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.16
6. Amount of fee enclosed: $ 3,040 . 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 Denton Lee E-mail Address [e-mail]
Telephone [phone] cell *N/A Fax # NIA
Ir
10
Landowner(s) of Record (attach accompanied page to list additional owners):
McLemore Farms LLC 919-516-3005
Name Telephone
2 Annandale Dr 2 Annandale Dr
Current Mailing Address Current Street Address
Clayton NC 27520 Clayton NC
City State Zip City State
Deed Book No. 06149 Page No. 0615 & 0618
NIA
Fax Number
27520
Zip
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):
McLemore Farms, LLC [e-mail]
Name E-mail Address
2 Annandale Dr 2 Annandale Dr
Current Mailing Address
Clayton NC 27520
City State
Telephone [phone]
Current Street Address
Clayton NC 27520
Zip City
Fax Number N/A
State
Zip

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:
NIA NIA
Name E-mail Address
NIA NIA
Current Mailing Address
NIA
City
Telephone N/A
State
Zip
Current Street Address
NIA
City State Zip
Fax Number N/A
(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:
NIA
Name of Registered Agent
NIA
Current Mailing Address
NIA
City
Telephone N/A
NIA
E-mail Address
NIA
Current Street Address
NIA
State Zip City State Zip
Fax Number N/A
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.
Denton Lee
Member
Title or Authority
Date
I, }4011acd {E Ack(Y-"L5 a Notary Public of the County of
State of North Carolina, hereby certify that De-r o� 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 day of 1V3,4er1��f�2-(20
1' �►l.
Notary
Seal
My commission expires