NCC216983_FRO Submitted_20220106

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 Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (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. Heritage Place Phase 3 Section 2
1. Project Name g
2. Location of land -disturbing activity: County Rockingham City or Township Wentworth
Highway/Street Heritage Road Latitude 36.4486 Longitude -79.7424
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.26 Acres
6. Amount of fee enclosed: $130.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed' Yes x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Harry Rakestraw
E-mail Address [e-mail]
Telephone
Cell # 336-932-0890 Fax #
9. Landowner(s) of Record (attach
accompanied page to list additional owners):
Harry W. Rakestraw and wife Janet
B. Rakestraw 336-932-0890
Name
Telephone Fax Number
PO Box 283
283 Foch Farms Road
Current Mailing Address
Current Street Address
Wentworth NC
27375 Reidsville NC 27320
City State
Zip City State Zip
10. Deed Book No.1525
Page No. 2374 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who
are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or finn is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Wentworth Holdings, LLC [e-mail]
Name
E-mail Address
PO Box 283
283 Foch Farms Road
Current Mailing Address
Current Street Address
Wentworth NC
27375 Reidsville NC 27320
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:
Harry Rakestraw [e-mail]
Name of Registered Agent E-mail Address
PO Box 283 283 Foch Farms Road
Current Mailing Address Current Street Address
Wentworth NC 27375 Reidsville NC 27320
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.
Harry Rakestraw Registered Agent
Type or print name Title or Authority
11 /03/2021
Sign re Date
a Notary Public of the county of Rockingham
State of North Carolina,' hheereeby certify that Harry Rakestraw 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 3 day of November 2021
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