NCC221247_FRO Submitted_20220404

MW_
WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
.� SEDIMENTATION POLLUTION CONTROL ACT
WADENo 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
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH C)AkOHNA 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 Groves at Deerfield Phase 5
2. Location of land -disturbing activity: Jurisdiction Wendell
Highway/Street _ Hoyleholly Trace Latitude 35d46'13.556"
(Wake Co. or Municipality)
Longitude 78d21'45.531"
3. Approximate date land -disturbing activity will commence: 12/1 /2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 15.7
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lucius S Jones, Jr E-mail Address [e-mail]
Telephone Cell # 919-427-3706 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Lucius S Jones, Jr 919-427-3706
Name(s) Telephone
Po Box 128
Current Mailing Address
Mendell NC 27591
City State Zip
8. Deed Book No. 000616
Part B.
Current Street Address
City
Page No. 00-E-
State
luciusjone lu iU� gmail. cor
Fax or E-mail address
Zip
Provide a copy of the most current deed.
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):
Lucius S Jones Jr
Name
PO Box 128
Current Mailing Address
Wendell NC 27591
City State Zip
Telephone [phone]
luciusjoneslucius(cDgmail com
E-mail Address
current Street Address
City State Zip
Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Telephone
Fax Number
State Zip
State Zip
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.
Lucius Jones
Type or,print name
Owner
Title or Authority
-r
i; -- 10/28/2021
Signature Date
---------------------------------- -
I,��rt f1�(ZOYy��Et1{-tom a Notary Public of the County of t
State of North Carolina, hereby certify that U-0Nt S
personally be appeared
p Y •,tp5�mq►t��s day and being duly sworn acknowledged that the above form was executed by him.
Witne4s`�0 dparirlQ�►,�seal, this h� day of 20_
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NOTARY ; rn 1.0 (�
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14 COUNT