NCC240774_FRO Submitted_20240318

WILSON
N OV,I rl
Financial Responsibility-Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson Sedimentation and Erosion Control Ordinance
before completing and filing this form with the City of Wilson Erosion Control Division. (*Indicate N/A if a question is not applicable)
Field Name Description Comments
PROJECT Tracking
number
Complete Application Received date
Application/N01
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 30000 other than SFE(30000)=1522,others=blank
Project or Site name Sherman Oaks Lot#5
Site Street Address 2601 Tilghman Road
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27893
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date March 15,2024
Total Acres of
Disturbance 1.62 ACRES
FRO-First Name John **MUST be Financially Responsible Owner Person**
FRO-Last Name Benson **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Landmark Development Co.of Wilson,Inc. **MUST belong to Financially Responsible Owner**
FRO-eMail Address John Benson<[e-mail]> **MUST belong to Financially Responsible Owner**
FRO -Mailing Street
Address P.O.Box 1607 **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text 712 Goldsboro Street,SW **MUST belong to Financially Responsible Owner**
FRO-Mailing City Wilson **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27894-1607 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.758
Longitude:Decimal
Degrees
-77.919

WILSON
NORTH CAROLINA
(#)ACRES TO BE DISTURBED 1.62 AC X$150.00/ACRE=$243.00
Person(s)or Firm(s)financially responsible for this land disturbing activity:(If out of state,a registered agent in North Carolina
must be used.)
In case of a violation please list the preferred contact(either the Financially Responsible Person or Registered Agent on the line
below:
John L.Benson,President Ronnie L.Sutton,PE
Financially Responsible Person Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by me while under oath.(This
form must be signed by the Financially Responsible Person if an individual or by an officer,director,partner,and attorney-in-fact,
or other person with authority to execute instruments for the financially responsible person if not an individual.)
February 12,2024
Date
Title or Authority
President, Landmark Development Co. of Wilson, Inc.
g_h-gy( %. ,n�
Sig“ture
John L. Benson
Type or Print Name
President 2-12-24
Title Date
ber 7 /Jtc n ;r ,a Notary Public of the County of 1 ,State of North Carolina
hereby certifies Q NO`S 1'
iQhY\ L. Lien or. personally appeared before me this day and under oath acknowledged that the
above form was executed by him. LA
I -I_ -
Witness my hand and notary seal,this day of " rlit Z0 V-\
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(Notary Public) J"t0 > �� i. WA/ '';.
yexpires � RY
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