NCC221386_FRO Submitted_20220408

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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
iNOM 11 CAROLI NIA 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 Lot 24 Shadow Creek E—* fct )-.os
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 12801 Durant Road Latitude 35.9136 Longitude-78.6263
3. Approximate date land -disturbing activity will commence:
February 28, 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): single family residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.99 acre
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Erin Hartmann E-mail Address [e-mail]
Telephone [phone]
Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
(m) -OS/7-
SCE Property Development, LLC
919 387 1455
Names)
Telephone Fax or E-mail address
2501 Reliance Avenue
Same
Current Mailing Address
Current Street Address
Apex NC 27539
Apex NC 27539
City State Zip
City State Zip
8. Deed Book No. 018421 Page No.
244 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):
Tripp Loyd Builders, LLC
[e-mail]
Name
E-mail Address
2501 Reliance Avenue
2501 Reliance Avenue
Current Mailing Address
Current Street Address
Apex NC 27539
Apex NC 27539
City State Zip
City State Zip
Telephone [phone]
Fax Number 1`119)

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:
N/A
Name
Current Mailing Address
City
Telephone
State Zip
E-mail Address
Current Street Address
City State Zip
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:
N/A
Name of Registered Agent
Current Mailing Address
City
Telephone
State Zip
E-mail Address
Current Street Address
City State Zip
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.
Frank R. Loyd III
Type or print
Signature
Manager
Title or Authority
�zjg/aoaa
Date
I, 'Lr (► i L. A a ► Arna h n _,a Notary Public of the County of
1 J''aKe-
State of North Carolina, hereby certify that Lol d I 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 4� day of }-ejo ✓ aiM , 20 ,z �-
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N O T A R Y?% Notary
g 11-21-2026 My commission expires
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