NCC221887_FRO Submitted_20220613

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 Beverly Place Lots 156, 188-210
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Location of land -disturbing activity: City or Township Johnston Co
Highway/Street Reedy Creek Rd Latitude 35.502445 Longitude-78.522560
Approximate date land -disturbing activity will commence: Spring 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.29
Amount of fee enclosed: $ 3,800.00 . 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.
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:
NameAshley Turner E-mail Address [e-mail]
Telephone cell # 919-917-3742 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
SDH Raleigh, LLC c/o Mike Kahm
Name Telephone Fax Number
2520 Reliance Avenue
Current Mailing Address Current Street Address
Apex NC 27539
City State Zip City State Zip
10. Deed Book No.06169,06138 Page No. 0697,0836
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):
SDH Raleigh, LLC c/o Mike Kahm [e-mail]
Name E-mail Address
2520 Reliance Avenue
Current Mailing Address Current Street Address
Apex NC 27539
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:
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.
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Vice President Land Development
I me or Autnority
Kim Fullerton , a Notary Public of the County of Wake
State of North Carolina, hereby certify that G. Michael Kahm appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial set�i�►rrrr this 15th day of March 2022
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