NCC233801_FRO Submitted_20240103

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 McGee's Crossroads ABC Store
2. Location of land-disturbing activity: City or Township Pleasant Grove
Latitude 35.51496 Longitude-78.56786
Highway/Street NC210
3. Approximate date land-disturbing activity will commence: Upon receipt of permits
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .31
6. Amount of fee enclosed: $760.00 . 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 11 No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chad Stewart E-mail Address [e-mail]
Telephone Cell# 919-422-1781 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Johnston County Board of Alcoholic Control
Name Telephone Fax Number
PO Box 909
Current Mailing Address Current Street Address
Smithfield NC 27577
City State Zip City State Zip
10. Deed Book No. 6283 Page No. 795
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):
Same as above
Name E-mail Address
Current Mailing Address Current Street Address t t f��
City State Zip City State 4' 1 �� 'Zip
Telephone Fax Number C, ¢ ��

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.
Chad Stewart Manager
Type i ame Title or Authority
/y I -( -
Signatu e Date
- , a Notary Public of the County ofQ , {vim
State of North Carolina, hereby certify that )&• S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. II l
Witness my; 4Votarial seal, this I—i day of J , 20 3
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�' i Notary
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