NCC224218_FRO Submitted_20230123

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 a -mall and/or fax Information unavailable, place N/A in the blank.)
Part A.
1. Project Name Black Forest Pointe
2. Location of land -disturbing activity: City or Township Pleasant Grove
Highway/street SR 1303 Latitude 35.47355 Longitude -78.60935
3. Approximate date land -disturbing activity will commence: 11-g 1 -2 022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas),10.1
150.0� (PER MlT 7RANSFFR SEE)
6. Amount of fee enclosed: $ . 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.
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 Michael D. Weeks E-mail Address [e-mail]
Telephone[phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Land Associates Dev., LLC 919-894-7587
Name Telephone Fax Number
P.C. Box 2167 6420 Benson Hardee Rd.
Current Mailing Address Current Street Address
Angier NC 275DI Benson NC 27501
City State Zip City State Zip
10. Deed Book No. 6294 Page No. 300
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):
Land Associates Dev., LLC [e-mail]
Name E-mail Address
P.O. Box 2167 6420 Benson Hardee Rd.
Current Mailing Address Current Street Address
Angier NC 27501 Benson NC 27F04
City State Zip City State Zip
Telephone[phone] 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
Current Mailing Address
City
Telephone
E-mail Address
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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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 sighed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by are 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.
Michael D. Weeks
Type or print name
.- gna ure
Member/Manager
Title or Authority
at�tg
I, , �� , a Notary Public of the County of
State of North Carolina, hereby certify that �M11rhul b . V V--- 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 __Cday of 0, 20.oz,
iilti;iSt!4SI! IFPFPh7pggr
TA, 1Votary
Seal
My Commission expires
4
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