Financial Responsibility Form 2025

10 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 2 Location of land - disturbing activity City or Township Highway Street Latitude Longitude 3 Approximate date land - disturbing activity will commence 4 Purpose of development residential , commercial , industrial , institutional , etc 5 Total acreage disturbed or uncovered including off - site borrow and waste areas 6 Amount of fee enclosed The application fee of 50000 per acre rounded up to the next acre is assessed for the first 10 acres and an additional 250 per acre for each additional acre rounded up to the next acre _____ 7 Has an erosion and sediment control plan been filed Yes_ No Enclosed 8 Person to contact should erosion and sediment control issues arise during land - disturbing activity ____ Name E - mail Address Telephone Cell # Fax # 9 Landowner s of Record attach accompanied page to list additional owners Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip 10 Deed Book No Page No 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 Name E - mail Address Current Mailing Address Current Street Address City State Zip City State Zip Telephone Fax NumberPage2 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 Type or print name Title or Authority Signature Date I , , a Notary Public of the County of State of North Carolina , hereby certify that 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 day of , 20 Seal Notary My commission expiresPage