NCC223944_FRO Submitted_20221129

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. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project NameJohnson Ridge Subdivision
2. Location of land -disturbing activity: Count Johnston City or Township Four Oaks
Old School Rd 35.4483461-78.4653317
Highway/Street Latltude(decimal degrees) LOngitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: Fall 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)
500 00
I
6. Amount of fee enclosed: $ The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ethan Averette
Phone: Office # 252-459-8196
E-mail Address [e-mail]
Mobile #
919-725-4213
Landowner(s) of Record (attach accompanied page to list additional owners):
Dewayne L Johnson 919-631-4876
Name Phone: Office #
2818 Hunter Run
Current Mailing Address
Florence, SC 29505
2818 Hunter Run
Mobile #
Current Street Address
Florence, SC 29505
City State Zip City
10. Deed Book No. 3580 Page No. 490
State
K.
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Old School Road, LLC
Company Name
401 N 2nd Street
Current Mailing Address
Smithfield, NC 27577
City State Ziip
Phone: Office# nil kol
kwcamaro67@gmail .com
E-mail Address
401 N 2nd Street
Current Street Address
Smithfield, NC 27577
City State
Mobile # [phone]
g
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
David Jackson
Name of Registered Agent
401 N 2nd Street
Current Mailing Address
Smithfield, NC 27577
City State Zip
[e-mail]
E-mail Address
401 N 2nd Street
Current Street Address
Smithfield, NC 27577
City
State Zip
Phone: Office # �t '— g3q—6101 Mobile # [phone]
"_�vic L� jccck Sari
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
David Jackson
or
nature
Registered Agent
Title or Authority
2
Date
1 a Notary Public of the County of
State of North Carolina, hereby certify that zzG%.SOh appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 3,4 day of �' 20
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office # Mobile #
Current Mailing Address
City State
Deed Book No.
Landowner 3 of Record:
Name
Current Street Address
Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #

9. Landowner of Record Letter of Consent
Dewayne L Johnson
2818 Hunter Run PIN: 165200-90-0479
Florence, SC 29505
Land Owner Consent. As a landowner, I provide my consent for land -disturbing
activities to occur on the property listed in Part A by the person or entity listed in Part
B, Item 1 of the Financial Responsibility/Ownership Form.
9-z-zdZZ LAmy Z)e�L)ayne TO�W�01-\
Date Type or Print Name
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Telephone Fax Title or Authority
pICIOUr,
Email