NCC243540_FRO Submitted_20241115

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 Chamblee North - Lots 1, 3, 7-12, 17-20, 22-39, 42-43
2. Location of land-disturbing activity: City or Township Johnston County
Highway/Street Lassider Road Latitude 35.4945 Longitude -78.4931
3. Approximate date land-disturbing activity will commence: Fall 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 30.88 ac
6. Amount of fee enclosed: $ 3,200.00 . 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 Ashley 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, 06736, 06693 page No. 0549, 0025
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:
Smith Douglas Home [e-mail]
Name of Registered Agent E-mail Address
3412 Apex Peakway
Current Mailing Address Current Street Address
Apex NC 27502
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.
G. Michael Kah Vice President Land Development
Typ- r o int Title or Authority
S'.nat Date
I, \rkeY-- -u tjP(fCfr> , a Notary Public of the County of \6
State of North Carolina, hereby certify that GN- iinkchG-e I Kq appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notariRituakiMs I day of Of,tc e.( , 20 AL-{
A.,�. -' Notary
Seal
T. `BLtO My commission expires tQ/l ► a�(4.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Durham Land Acquisition
Name Phone: Office# Mobile#
PO Box 725589
Current Mailing Address Current Street Address
Atlanta, GA 31139
City State Zip City State Zip
Deed Book No. 06543 Page No. 0530 Provide a copy of the most current deed.
Landowner 3 of Record
Name Phone Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No Page No. Provide a copy of the most current deed
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Smith Douglas Homes _
Lot PIN Owner Book Page
1 165301-16-6290 Durham Land Acquisition 06543 0530
3 165301-25-1015 Durham Land Acquisition 06543 0530
7 165301-25-0495 SDH 06736 0549
8 165301-25-0595 Durham Land Acquisition 06543 0530
9 165301-25-0685 Durham Land Acquisition 06543 0530
10 165301-25-0785 Durham Land Acquisition 06543 0530
11 165301-25-0885 Durham Land Acquisition 06543 0530
12 165301-25-0985 Durham Land Acquisition 06543 0530
17 165301-26-1514 Durham Land Acquisition 06543 0530
18 165301-26-0668 Durham Land Acquisition 06543 0530
19 165301-16-8697 Durham Land Acquisition 06543 0530
20 165301-16-7554 Durham Land Acquisition 06543 0530
22 165301-16-6350 Durham Land Acquisition 06543 0530
23 165301-16-7167 Durham Land Acquisition 06543 0530
24 165301-16-7055 Durham Land Acquisition 06543 0530
25 165301-15-7924 Durham Land Acquisition 06543 0530
26 165301-15-7814 Durham Land Acquisition 06543 0530
27 165301-15-8641 SDH 06693 0025
28 165301-15-7641 SDH 06693 0025
29 165301-15-6651 SDH 06693 0025
30 165301-15-5661 SDH 06693 0025
31 165301-15-4674 SDH 06736 0549
32 165301-15-3678 Durham Land Acquisition 06543 0530
33 165301-15-2783 Durham Land Acquisition 06543 0530
34 165301-15-1796 Durham Land Acquisition 06543 0530
35 165301-15-1398 Durham Land Acquisition 06543 0530
36 165301-15-2371 Durham Land Acquisition 06543 0530
37 165301-15-3257 SDH 06736 0549
38 165301-15-4168 SDH 06693 _ 0025
39 165301-15-7314 SDH 06736 0549
42 165301-15-7026 Durham Land Acquisition 06543 0530
43 165300-14-7965 Durham Land Acquisition 06543 0530