NCC231037_FRO Submitted_20230414

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM PSEDIMENTATIONPOLLUTIONCONTROLACTWATER RESOURCES (1),-
105-B Upchurch Street O :`: ., y, 2
Town of Apex, North Carolina 27502 �2yv
CAS
Contact: James Misciagno -
Phone: [phone] E-Mail: [e-mail]
No person may initiate any land-disturbing activity on twenty(20)thousand square feet or more before this form has been
completed and filed with the Town of Apex Water Resources Department.
PART A
Name of Project:WILLIAMS GROVE
Location of Land-Disturbing Activity:4525 GREEN LEVEL WEST RD
Approximate Date Land-Disturbing Activity will Commence:SPRING 2022
Acreage of Land to be Disturbed:45.58
Latitude: 35.768049 Longitude: -78.938723
Land Owner(s)of Record(use blank page to list additional owners):
Name:WILLIAMS,ELIZA C Name:
Current Mailing Address: Current Mailing Address
4525 GREEN LEVEL WEST RD
City,State,Zip:APEX NC 27523-7516 City,State,Zip
PART B
Person or firm financially responsible(developer)for this land disturbing activity. Financial responsibility includes,but
may not be limited to: payment of civil fines and criminal penalties and any other costs associated with bringing the
project into compliance with the Town of Apex Soil Erosion and Sedimentation Control Ordinance.
Name of Person or Firm:APEX NC 27523-7516
Telephone:[phone] E-mail:
Current Mailing Address: Street Address(if different from mailing address)
4020 WESTCHASE BLVD,SUITE 470
City,State,Zip:RALEIGH NC 27607 City,State,Zip
Revised 3/27/2020 Page 1

U Specifications (seedbed preparation, soil amendments, construction and seeding schedules, etc.)
® Indicate Watershed Protection Overlay District [Primary or Secondary] (describe water quality protection methods)
One Set of Calculations, Including:
B Peak Discharge of Runoff(pre-construction, construction, and final phase discharges for the site up to and at the
property line)
* Temporary Devices (sediment storage and Q25 capacity and dimensions)
• Ditches, Swales, and Channels (Q25, V10, tractive force/shear stress, capacity, and geometry)
U Dissipaters (Q10 velocities, stone size, and dimensions)
* Storm Culverts and Inlets (inverts, length, slope, Q100 and HW100 in natural drainage ways; Q10 and HW10 for all
others)
Other Requirements
® R4OW-80W Zoning (locations, dimension, details, calculations, and specifications for watershed protection measures)
U Narrative Describing the Nature and Purpose of Construction Activity (phasing, clearing and grubbing, special
sequencing, experimental devices, etc.)
O Name of Re iving Wat (only where stormwater system discharges are to occur)
11/1/2021
Signatur of pplica Date
PART C (Other Related Regulatory Requirements)
NPDES
The Federal Clean Water Act requires that National Pollutant Discharge Elimination System (NPDES) permits be
obtained for discharges of stormwater runoff from construction activities disturbing one or more acres. In North
Carolina,the NPDES stormwater discharge permit for construction activities is considered automatically effective
once the NC Division of Land Resources or the delegated local program approves the Soil Erosion and
Sedimentation Control Plan. Applicants will receive a copy of the permit once the Soil Erosion and Sedimentation
Control Plan has been reviewed and a Letter of Plan Approval is issued. Should you have questions regarding
NPDES permit, please contact Sara Knies, (DENR-Surface Water Protection) at(919) 791-4258.
Wetlands
Any project having the possibility of wetlands (indicators being flood hazard solid or alluvial soils, wetland
vegetation, blueline streams, etc.) within its boundaries should be investigated by the U.S. Army Corps of
Engineers prior to any disturbance to determine the existence of wetlands and any requirements thereof. For
information contact James Lastinger, Raleigh Field Office, U.S. Army Corps of Engineers, [phone] ext. 32.
Page 2

If the financially responsible party is not a resident of Wake County,complete the following for an appointed agent, in
Wake County,to receive any notice, process,pleading in any action or legal proceeding arising from a violation of the
Town of Apex Soil Erosion and Sedimentation Control Ordinance. By signing below,it is agreed that any notice,process,
or pleading against the person or firm who is financially responsible for this land-disturbing activity may be served on
the undersigned and shall be of the same force and effect as if served on the financially responsible person or firm. The
intent of this provision is to establish the presumption that the constructive notice from the Town of Apex will be
addressed through the undersigned agent.
Name:
Telephone:
Current Mailing Address: Street Address(if different from mailing address)
City,State,Zip: City,State,Zip
Signature:
If the financially responsible party is a partnership or other person engaging in business under an assumed name,complete
Page 4 of this form, or attach a copy of the Certificate of Assumed Name or Partnership as recorded in the Register of
Deeds. If the financially responsible party is a corporation,complete the information on Page 5 of this form and submit a
current copy of the Annual Report as filed with the Secretary of State.
The information contained in this form is true and correct to the best of my knowledge and belief and was provided by
me while under oath. (This form must be signed by the financially responsible person if an individual or by an officer,
director,partner,or registered agent with authority to execute instruments for a corporation or partnership if it is the
financially responsible party). I agree to provide corrected information should there be any change in the information
provided herein.
Name: BRIAN KETCHEM, PE, LEED-AP Date: / 7/ 76i
Title or Authori • DIRECTOR OF LAND DEVELOPMENT
Signature: I _
I, )OIC.1L4Y� cUe,K a Notary Public of the County of \'`J Ol , State
of North Carolina hereby certify that &S O" l(Q-t CIA LW‘ personally appeared before me this
day and under oath acknowledged that the above form was executed by him/her. Witness my hand and seal ,hisrirrrr,,1
e Y N i/i
()CAC) •�`�\ PGA �<F`��':
day of OC.� ) , 2.0 2 1 `�, 'Notary Public '_
`DEAL
n ? Wake
County
Wary My Commission Expires My Comm. Exp. _
12-04-2023 ' .
Financial responsibility encompassespersonal liabilitybytheperson signing this disclosure form, if a pgittl CARO��o`�
p Y p g gpl�ri►iit��0
partnership or if an officer or director of a corporation which is either:(a)dissolved lawfully under North Carolina statutes:
(b) suspended from transacting business in North Carolina by the North Carolina Secretary of State; (c) insolvent; (d) in
bankruptcy; (e) undercapitalized to the extent it is unable to comply with the Soil Erosion and Sedimentation Control
Ordinance;or(f) a "shell" corporation.
Revised 3/27/2020 Page 2

PART C
Contractors and/or subcontractors(person(s)or firm(s)engaging in the land-disturbing activity):
Name Person or Firm: Name of Person or Firm:
STANLEY MARTIN HOMES
Telephone:919'977'8760 Telephone:
Email: Email:
[e-mail]
Current Mailing Address: Current Mailing Address
4020 WESTCHASE BLVD,SUITE 470,RALEIGH NC 27607
City,State,Zip:919.977.8760 City,State,Zip
The information contained in this form is true and correct to the best of my knowledge and belief was provided by me
while under oath. (This form must be signed by the person or firm engaging in the land-disturbing activity of an
individual or by an officer, director, general partner, attorney-in-fact, or other person with authority to execute
instruments for the entity engaging in the land-disturbing activity if not an individual. I agree to provide corrected
information should there be any change in the information provided herein. /�(
Name:BRIAN KETCHEM,PE,LEED-AP Date: v�' / ��
Title or Author' •DIRECTOR OF LAND DEVELOPMENT
Signature: )"--1
I, Jack‘i h C `L a Notary Public of the County of ( I ,State of North
Carolina hereby certify that V1 C& \ \ `'e'\ t ,tvv personally appeared before me this
day and under oath acknowledged that the above form was executed by him/her. Witness my hand and seal this
S- day of 0 { , 201-
SEAL
`cam �Z)�►I(23
Nry My Commission Expires
Notary Public
Wake
County
My Comm. Exp.
/- 12-04-2023 Q
09,
Revised 3/27/2020 Page 3