NCC222404_FRO Submitted_20220701

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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
WAKECounty 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 CAROLI NA 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 Prescott Manor Phase 2
2. Location of land -disturbing activity: Jurisdiction Wake County make Co. or Municipality)
Highway/street Perry Bluff Dr Latitude 35.00629 Longitude-78.60629
3. Approximate date land -disturbing activity will commence: May 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or
uncovered (including off -site utilities and borrow/waste
areas):.5.61 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
T0171 AnhUt
Name
E-ma�iAdd�[e-mail]
919.291.3023
Cell #Same Fax # NIA
Telephone
7. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached page
Name(s)
Telephone Fax or E-mail address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
8. Deed Book No. See attached page
Page No. 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):
A2 Group, LLC tj*anhutaanhutprop.com
Name
610 Presidents Walk Ln
Current Mailing Address
Cary NC
City State
Telephone [phone]
E-mail Address
Same
Current Street Address
27519 Same
Zip
City State Zip
Fax Number n/a

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,
E-mail Address
Current Street Address
State Zip 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
Current Mailing Address
City
Telephone,
State
918
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.
Tom Anhut Manager
Typ,q or print name Title or Authority
-14-22
L IIJ 1
Signature Date
a Notary Public of the County of
State of North Carolina, hereby certify that 4 appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
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LANDOWNERS OF RECORD
SANCTUARY PARTNERS LLC
610 PRESIDENTS WALK LN
CA RY NC 27519-6851
DEED BOOK 16962, PAGE 1357
KEITH, JAMES C KEITH, JIMMY D
7709 STONY HILL R D
WAKE FOREST NC 27587-7510
DEED BOOK 8837, PAGE 2212
KEITH, JERRY W TRUSTEE KEITH, SANDRA E TRUSTEE
7461 TOVVC H ESTE R DR
CHESTERFIELD VA 23832-7755
DEED BOOK 18427, PAGE 2379 AND DEED BOOK 150►40, PAGE 2456