NCC222406_FRO Submitted_20220701

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
IWAKEI 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
IN 0 RTI I C A R 0 L. I i*',: A 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 Sancutary at Lake Wheeler Subdivision
2. Location of land -disturbing activity: JurisdictionWake County (Wake Co. or Municipality)
Highway/Street Lake Wheeler Rd Latitude35.70576 Longitude -78.68913
3. Approximate date land -disturbing activity will commence - April 2i122
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or
uncovered (including off -site utilities and borrow/waste
areas):, 11.90 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameTom At1hUt
E-mail [e-mail]
Telephone [phone]
Cell # Same Fax # N/A
7. Landowner(s) of Record (attach accompanied page to list additional owners):
DAVIS, HERBERT EDWARD JR n/a
Name(s)
Telephone Fax or E-mail address
9239 THAYER Rd
Same
Current Mailing Address
Current Street Address
CHARLOTTE NC
28214 Same
City State
Zip city State Zip
8. Deed Book No.8076
Page No. 1420 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 informalion).-
A2 Group LLe [e-mail]
Name E-mail Address
610 Presidents Walk Ln Same
Current Mailing Address
Cary NC
City State
Telephone [phone]
Current Street Address
27519 Same
Zip city State Zip
Fax Numbern/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 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:
Name of Registered Agent
Current Mailing Address
City
Telephone,
State
E-mail Address
Current Street Address
Zip 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
TypApr print name,,, ,-
Signature
Manager
Title or Authority
Date
---
rr 44ary a Notary Public of the County of Wed(-t
State of North Carolina, hereby cel that -rhow)as �js Anhe appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial sea[, this I iTiay of �OeUj"6Qr _...7 20�
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Wake County Financial Responsibility/Ownership Form Additional Owner Addendum
Part A. 7. Landowner(s) of Record
DAVIS, BRIAN EDWARD
5708 LAKE WHEELER RD
RALEIGH NC 27603-3937
Part A. 8. Deed Book No. 12-E, Page 323