NCC220158_FRO Submitted_20220110

W
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COUNTY
NORTH CAROI INA
Part A.
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
County Unified Development Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by Wake County Department of
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
1. Project Name�� -
Z. Location of land -disturbing activity: Jurisdiction (Wake Co. or Municipality)
Highway/Street - Latitude 35 . g LA 0 -I Longitude - 79 , LA- S9 a
3. Approximate date land -disturbing activity will commence: 20Z
4. Type of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1. D1, —
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
7
:�
TelephoneQl Cell # Cl "1 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Lie . 19 3qs I rho
Name(s) Telephone Fax or E-mail address
Current Mailing AcTdress
�--
Current Street Address
' 7 [
State Zip City State Zip
�'r
City
Deed gook No. _-1 X_ q O S,' _ Page No._(0 _ Provide a copy of the most current deed.
Part B.
I. 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):
Name E-mail Address r
Current Mailing Address
City State Zip
Telephone .S /,L
d--
Current Street Address
City State
Fax Number
Zip

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
City
Telephone
State Zip
E-mail Address
Current Street Address
City
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:
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.
Type or prirft name
Sign #re
Title or Authority
10/z2110-62-1
Date
1, & I&e �-' Y _, a Notary Public of the County of �" Z�
State of North Carolina, hereby certify that Ye s appeared
personally before me this day and being duly sworn acknowl, dged that th6 above form was executed by him.
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Witne r htarial seal, this day of (it- ��y,� 20)
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Notary
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