NCC223209_FRO Submitted_20220912

JOHNSTON COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Beverly Place Lots 89-91 & 108-118
2. Location of land -disturbing activity: City or Township Johnston CO
Highway/Street Reedy Creek Rd Latitude 35.502445 Longitude -78.522560
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.98
6. Amount of fee enclosed: $ 1,400.00 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.
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 Ashley Turner E-mail [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. 06169,061 38 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
City State Zip
Telephone
Current Street Address
City
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 Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
M l kce
Type or prim name Title or Authority
I, , a Notary Public of the County ofal��`
State of North Carolina, hereby certify that K V),e- 1�-�q�r-�n-, _ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and not? fi i i day of�e01-
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ep-,TA'4i- ^ t�&�
Notary
Seal :'Z O&BLOG V
?0 - t10- My commission expires 1OZIS
''���` CO

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:
GHD-Beverly, LLC
Name
Phone: Office # Mobile #
1330 Sunday Dr
Current Mailing Address
Current Street Address
Raleigh, NC 27607-5196
City State
Zip
City State Zip
Deed Book No. 05210
Page No.
0790 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.