NCC220942_FRO Submitted_20220303

ERS
.. WAKE COUNTY FINANCIAL RESPUT ON CONTROL ACTHIP FOR
SEDIMENTATION BOLL the Wake
activit on one or more acres as covered
erosion and
No person may In any land -disturbing Y artment of
feted and approved by Wake County pep
County Unified Development Olaeen comp before this form and an acre question's not
WAKEsedimentation control plan have Y or r. and, if the q
COUNTY Environmental Services, Water Quality Division. (Please typep
NOR rH `""""`� applicable, place NIA in the blank.)
Part A. /I 5 1�yrI L L
1 • Project Name (e_ r (Wake Co. or Municipality)
2, Location of land -disturbing activity: Jurissdicti W U p 3y yJ ~
%1'� Z,�b 01AS �# 'C .' _� 3 7 �/ �I Longitude
�' atitude
H ighway/Street
� t
Approximate date land -disturbing activity will commence: lZ n � � I �
3. App i`
4. Type of development (residential, commercial, industrial, institutional, etc.):r�
disturbed or uncovered (including off -site utilities and borrow/waste
5. Total acrea e
areas):
contact should erosion and sediment control issues arise during land -disturbing activity:
d
�• Person to
E-mail Address
Name 7-- Fax #
Telephone
�l L �Lf(o ✓ � � � Cell #
7. Landowner(s) of Record (attach accompanied page to list additional owners}:
All 22 s� /a99
Fax or E-mail address
Telephone
Name(s)
j G�,S 3 . A//-' a-f!yl
` 7�1Z Current Street Address
Current Mailing Address
`? Az 74o3 Zip
State Zip City State
City 7
-2- Gi Page No.� T Provide a copy of the most current deed.
S. Deed Book No. g
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):
�Gtiz- p;z�P� /✓c-6rr Cpr-
Name E-mail Address
Current Mailing Add ss
City G�State Zip
Telephone/�?
Current Street Address
City
Fax Number
/� q State Zip

III. GENERAL INFORMATION
L Property Owner (s)
Name:
Street Address:
Mailing Address/
E-Mail Address -
Phone#: ( 1- J 9 !iz
the name of the corporation, individual, etc., who owns the property):
Cell#:
Fax#:
2. Applicant* (Person to whoa/ all c rrespondence will be sent):
Name: f� l/C i
Firm/other: k x T 02 .0�_S C C
Street Address:
Mailing Address:
E-Mail Ad ess:
Phone#: Fax#:
Relationship to Owner: Ole r7�lt
*.If not a resident of North Carolina, a North Carolina agent must be designated for the purpose of
receiving correspondences.
IV. APPLIICANT'S CERTIFICATION
PRINT NAME D PJ v J, Q l 1!
SIGNATURE r`
DATE
OWNEWPERSON PWANCIALLy RESPONSIBLE
V. FEES
Individual Lot Plan Review Fees
S&E &- 7 ,,�* x $250.00
Disturbed acres (to hundredth of acre) round to nearest dollar
Fees prorated
Individual Lot Permit Fees j
S&E 11P. % .J" x $250.00
Disturbed acres (to hundredth of acre) round to nearest dollar
Fees prorated
Fees — invoiced upon application
IF A LOT HAS A STREAM CROSSSING submit DWO, 404 and/or 401 approval document
*For flood hazard soils or FEMA crossing, Flood Permit is required - apply to Permit Portal for
Flood Study Permit
Note: apply separately for building permit, well and septic through Permit Portal
3

To Whom It May Concern
!, Andrew Brooker, landowner of 1512 Meadows Bank Way, Raleigh, authorize NC Custom Homes LLC
to "permit and conduct" the land disturbing project on my lot.
Ia Notary Public of the County of Wake, State of North
Carolina, hereby Certify that 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 day of , 2022
"J"tOtt 11"J,,R, 1
A_ S•.
-' Notary
EV
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pUB\-�G , G a My Commission expires
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