NCC240188_FRO Submitted_20240119

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 Jones Farm Phase 3 Lots 1 , 3, 5-14
2. Location of land-disturbing activity: City or Township Cleveland Township
Highway/Street SR 1529 Angie Road Latitude 35.58915 Longitude -78.61490
3. Approximate date land-disturbing activity will commence: December 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (Including off-site borrow and waste areas): 8.02
6. Amount of fee enclosed: $ 1 ,200.00 . 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 No Enclosed iv
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name
Brian Herring E-mail Address [e-mail]
Telephone Cell# 919-650-8224 Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Great Southern Homes, Inc. 803-699-4734
Name Telephone Fax Number
90 N. Royal Tower Drive 214 North Peedin Avenue
Current Mailing Address Current Street Address
Irmo SC 29063 Irmo SC 29063
City State Zip City State Zip
10. Deed Book No. See Page Na. Attachment
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):
Great Southern Homes, Inc. [e-mail]
Name E-mail Address
90 N. Royal Tower Drive 90 N. Royal Tower Drive
Current Mailing Address Current Street Address
Irmo SC 29063 Irmo SC 29065
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:
Thomas Brian Herring [e-mail]
Name E-mail Address
933 Old Knight Road 933 Old Knight Road
Current Mailing Address Current Street Address
Knightdale NC 27u5 Knightdale NC 27545
City State Zip City State Zip
Telephone [phone] 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.
omas ian H rring Registered Agent
Ty r pri me Title or Authority
Sig a r Date
f
I, 06:4A it6 1' +4 M, a Notary Public of the County of N kn -}dh
State of North Carolina, hereby certify that Thomas Brian Herring appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
myc ) day of at VIUUY J►' 20 a 3
Witness hand and notarial seal, this ,
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