NCC215891_FRO Submitted_20211022

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.
Project Name Cattail Mills
2. Location of land -disturbing activity: City or Township O'Neals
Highway/Street NC 96 Latitude 35.67914 Longitude-78.27215
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.62
6. Amount of fee enclosed: $ 600.00 . The application fee of $300.00 per acre (rounded
up to the next acre) is assessed for the first 10 acres and an additional $100 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 X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Norwood Thompson E-mail Address [e-mail]
Telephone [phone] Cell # 919-740-8009 Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Cattail Family, LLC
Name
442 1/2 East Main Street
Current Mailing Address
Clayton NC 27520
City State Zip
919-553-5400 919-550-3814
Telephone Fax Number
442 1/2 East Main Street
Current Street Address
Clayton NC 27520
City State Zip
10. Deed Book No. 5937 Page No. 722-743
Part B.
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):
Cattail Family, LLC nthom son@walthom rou .com
Name E-mail Address
442 1/2 East Main Street 442 1/2 East Main Street
Current Mailing Address Current Street Address
_Clayton NC 27520 Clayton NC 27520
City State Zip City State Zip
Telephone [phone] Fax Number 919-550-3814

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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
(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
Current Mailing Address
City State
Telepho
E-mail Address
Current Street Address
Zip City
Fax Number.
State Zip
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.
wood Thom
or print
Managing Member
Title or Authority
._t 0
Signature Date
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a Notary Public of the County of�.�5e�
State of North Carolina, hereby certify that v 1 140 appeared
personally before me this day and being duly sworn acknowledged at the above form was
executed by him.
Witness my hand and notarial seal, this
Steven S. Sanderson
Notary Public
W ounty, NC
My CAmmi!s ires i I - 3, z2
day of 0 Z I
Notary
My commission expires , J