NCC230210_FRO Submitted_20230125

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Name2022 AC Water Main Replacements
2. Location of land -disturbing activity: County Johnston City or Township Selma, Kenly
us �w ro- sR pass. sa Faso. sre �+. aR 7oa. =.935.61205-78.41486
Highway/Street Latitude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: March 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal Water Mair
5. Total acreage disturbed -or uncovered (including off -site borrow and waste areas): 9.82
6. Amount of fee enclosed $1000.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kim Rineer E-mail Address [e-mail]
Phone: Office # (919)-989-5725 Mobile # Not Applicable
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached
Name
Current Mailing Address
City
rnone: urnce ;t
Current Street Address
State Zip City
State
Mobile #
Zip
10. Deed Book No. Page No. 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).
Johnston County (c/o Rick Hester)
Company Name
PO Box 2263
Current Mailing Address
Smithfield, NC 27577
City State Zip
Phone: Office # (919)-989-5100
[e-mail]
E-mail Address
309 E. Market St.
Current Street Address
Smithfield, NC 27577
City State Zip
Mobile # Not Applicable
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:
Not Applicable
Name of Registered Agent E-mail Address
Current Mailing Address
City State Zip
Phone: Office #
Current Street Address
City State Zip
Mobile #
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:
Not Applicable
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # 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.
Not Applicable
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Not Applicable
Engineering firm or other consultant
Individual contact person (type or print)
E-mail Address
Phone: Office # Mobile #
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.
Rick Hester
County Manager
Typin. name Title or Authority
e
L�-zL
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Signature Date
I, JQ� C . W o � 6(arc9 . a Notary Public of the County of �b1��►siy,n u�
State of North Carolina, hereby certify that R:c,���. 1kV%Ae,r 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 Z2 day of Vaex , 20 a
Wo
Seal 47 1- 1jj
o� y ,Q V Si
SAY, \ LJu.....,
P"�- 6. W g�-j
Notary
My commission expires 10. \-�' D, Oa b

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 #
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 3 of Record:
Name
Current, Mailing Address
City
Deed Book No.
Landowner 4 of Record:
Name
Current Mailing Address
Mobile #
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No..
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Recnrd-
Mobile #
State Zip
Provide a copy of the most current deed.
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.