NCC231524_FRO Submitted_20230518

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 Floyd Landing Phases 1-3
2. Location of land-disturbing activity: City or Township Smithfield
Highway/Street Hwy 70 Business Latitude 35.6432 _Longitude -.I;./1 I�
3. Approximate date land-disturbing activity will commence: September 2022
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):64.0 acres
6. Amount of fee enclosed: $ 10,550.00 . 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 I V
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Andrew Ross E-mail Address Andrew.Ross @FloydDevelopment.com
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. -
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):
Triangle Land Partners,LLC-Andrew Ross,Manager [e-mail]
Name E-mail Address
P.O. Box 5488 4201 Taylor Hall Place
Current Mailing Address Current Street Address
Cary NC 27512 Chapel Hill NC 27517
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.
Andre oss Triangle Land Partners, LLC Manager
Type r print n e Title or Authority
3 _ t'-t
Signature Date
I \T i'YCA+U , a Notary Public of the County of (A 62.-
State of North Carolina, hereby certify that Andrew Ross appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. /'
Witness my hand and notarial1u day of March 20
•
Ao-, INGRITH SERRATO
Notary Public, North CarolinaVY) CC
NM
+ rr'-" y ; Wake County
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Notary
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My commission expires S -� �

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:
Chatham Capital Group, LLC 919-703-6206
Name Phone: Office# Mobile#
1064 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield, NC 27577
City State Zip City State Zip
Deed Book No. 6221 Page No. 416 Provide a copy of the most current deed.
Landowner 3 of Record:
Chatham Capital Group, LLC 919-703-6206
Name Phone: Office# Mobile#
1064 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield, NC 27577
City State Zip City State Zip
Deed Book No. 6221 Page No. 472 Provide a copy of the most current deed.
Landowner 4 of Record:
Chatham Capital Group, LLC 919-703-6206
Name Phone: Office# Mobile#
1064 N. Lakeside Drive
Current Mailing Address Current Street Address
Smithfield NC 27577
City State Zip City State Zip
Deed Book No. 2634 Page No. 30-36 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.