NCC241533_FRO Submitted_20240521

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 CATTAIL PHASE 1 B
2. Location of land-disturbing activity: City or Township ZEBULON
Highway/Street NC HWY 96 N Latitude 35.41 _ _ _ Longitude-78.16
3. Approximate date land-disturbing activity will commence: N/A
4. Purpose of development(residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 10 ACRES
6. Amount of fee enclosed: $ 4,000 . The application fee of$400.00 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name JEREMY KEENY, PE. PLS E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
CATTAIL DEVELOPERS LLC 919-239-4747
Name Telephone Fax Number
1611 JONES FRANKLIN ROAD, SUITE 101
Current Mailing Address Current Street Address
RALEIGH NC 27606
City State Zip City State Zip
10. Deed Book No. 05937 Page No. 0722, 0744
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):
CATTAIL DEVLOPERS, LLC [e-mail]
• Name E-mail Address
1611 JONES FRANKLIN ROAD, SUITE 101 1611 JONES FRANKLIN ROAD, SUITE 101
Current Mailing Address Current Street Address
RALEIGH NC 27606 RALEIGH NC 27606
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:
ROB BAILEY( CATTAIL DEVELOPERS, LLC) RBAILEY a RAN DRDEV.COM
Name of Registered Agent E-mail Address
1611 JONES FRANKLIN ROAD, SUITE 101
Current Mailing Address Current Street Address
RALEIGH NC 27606
City State Zip City State Zip
Telephone [phone] 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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Type •r print name / Title or Authority
ignature Date
I, 1c. Cll fi1trcf , a Notary Public of the County of 1A/ .>I�e
State of North Carolina, hereby certify that o&&e rt- 7J . 730i 1 ie y 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 5 day of fif larch , 20A _
MARY K CLIFFORD
NOTARY PUBLIC
MAKE COUNTY Notary '
STAW4OF NORTH CAROLINA ��(�
My commission expires

Landowner: Cattail Family, LLC
Telephone:[phone]
Current Street Address:442 %2 Main Street,Suite 5
City: Clayton State: NC Zip: 27597