NCC216660_FRO Submitted_20211201

O-W WAKE 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 Wake
WACounty Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROLINA I Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
1. Project Name Haywood Glen Phase 3
2. Location of land-disturbingactivity: Jurisdiction Wake
y (Wake Co. or Municipality)
Highway/Street Old Knight Road Latitude 35.490652' Longitude-78.280310'
3.
4
Approximate date land -disturbing activity will commence: Winter 2021
Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas). 24
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Jones E-mail Address [e-mail]
Telephone [phone] Cell # Same Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton - Terramor, LLC
Name(s)
7208 Falls of Neuse Road
Current Mailing Address
Raleigh NC
.Y
8. Deed Book No. 018622
27615
Telephone
Same
Current Street Address
Same
State Zip City
Page No. 01703-01706
Fax or E-mail address
State
Provide a copy of the most current deed.
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. Include requested information):
D.R. Horton - Terramor, LLC [e-mail]
Name E-mail Address
7208 Falls of Neuse Road Same
Current Mailing Address Current Street Address
Raleigh NC 27615 Same
City State Zip City State Zip
Telephone [phone] Fax Number NSA

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone 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:
Michael L Jones
Name of Registered Agent
7208 Falls of Neuse Road
Current Mailing Address
Raleigh
City
NC 27615
State Zip
Telephone [phone]
[e-mail]
E-mail Address
Same
Current Street Address
Same
City State Zip
Fax Number N/A
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.
WL 3`�r
Type or print n
F
Signa ure
I 7j . t `'r it e- . . 414
Title or Authority
�,d-2��r
Date
l i LLa Notary Public of the County of
State of North Carolina, hereby certify that �0� 4`1 - • � Coif e-f- appeared
personally before me this day and being duly sworn acknowledged that the abo a form was executed by him
-
Witness my hand and notarial seal, this )t day of 20
MICHAEL L. JONES
Notary Public
Sea�Vake County
North Carolina
Notary }
My commission expires -1 _dl n _ j 0) Gl