NCC230874_FRO Submitted_20230330

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 Gregory Ridge Lots 1-33
2. Location of land -disturbing activity: City or Township Johnston Co
Highway/StreetLassiter Road Latitude35.501370 Longitude -78.511522
3. Approximate date land -disturbing activity will commence: Winter 2022/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.96 acres
6. Amount of fee enclosed: $3,300.00 . 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? Ye ❑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):
Stancil Builders Inc
Name Telephone FaxNumber
466 Stancil Road
Current Mailing Address Current Street Address
Angier NC 27501
City State Zip City State Zip
10. Deed Book No.06398 Page No.0474
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):
SDH Raleigh, LLC [e-mail]
Name E-mail Address
2520 Reliance Avenue
Current Mailing Address Current Street Address
Apex NC 27539
City State Zip City
Telephone [phone] Fax Number.
State
0

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 State Zip
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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.
G. Michael Kahm Vice President Land Development
Type or riot na Title or Authority
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Siatgre/ Date
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�Vate of North Carolina, hereby certify that (—del MiC h(U J<ilk N appeared
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personally before me this day and being duly sworn acknowledged that the above form was
executed by him. 112�ay of tl 20Q3
Witness my hand and notariqlAgg,, this
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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:
SDH Raleigh , LLC
Name
Phone: Office # Mobile #
2520 Reliance Ave
Current Mailing Address
Current Street Address
Apex, NC 27529
City State
Zip
City State Zip
Deed Book No.
Page No.
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.