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HomeMy WebLinkAboutNCC233334_FRO Submitted_20231109 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 N/A in the blank.) Part A. 1. Project Name Rock Pillar Road Property 2. Location of land-disturbing activity: City or Township Wilsons Mill/Smithfield Highway/Street Rock Pillar Rd. Latitude 35.55660 Longitude -78.40367 3. Approximate date land-disturbing activity will commence: 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.60 6. Amount of fee enclosed:$ 1.140 . 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 x Enclosed 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Michael Stewart E-mail Address stewartpeaaol.com Telephone 919-779-1855 Cell# Fax# 919-779-1661 9. Landowner(s)of Record(attach accompanied page to list additional owners): Rock Pillar Partners, LLC Name Telephone p Fax Number 14201 Wyndfield Cir Current Mailing Address Current Street Address Raleigh NC 27615 City State Zip City State Zip 10. Deed Book No. 6297 Page No. 141-144 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): Rock Pillar Partners. LLC ghassan.alawart gmaii_com Name E-mail Address 14201 Wyndfield Cir Current Mailing Address Current Street Address Raleigh NC 27615 City State Zip City State Zip Telephone 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. w — . )1E lie ki 4. Type or print name Title or Authority if — - - - at0 .3 Signature Date I, v}\ I CwtE r, � l. � C; Z 2 J V , a Notary Public of the County of I i c�.( State of North Carolina, hereby certify that ,M I-a1-1,0 L - Lir:LA- 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 i'�i day of `(c. ri1/ - , 20 ,. 3 \\\\\11 H11///al ,� �� `9 Notary — My commission expires kl J c 5 J?G a SJ PUBU C) / •0ic/ COON T\`