HomeMy WebLinkAboutNCC222433_FRO Submitted_20220722WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
7WAU No 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
.......
NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name Lot 11 Creedmoor Manor
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street HWY 5 0 Latitude 3 6. 0006 Longitude - 7 8. 6809
3. Approximate date land -disturbing activity will commence: 4-25-22
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 1 . 4 Acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Wagoner E-mail Address chris@wagonerhomes.com
Telephone Cell# 919-745-7489 Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Falls Lake Holdings, LLC 919-622-6802 gracaw59@gmail.com
Name(s) Telephone Fax or E-mail address
6112 Cresent Knoll Dr 6112 Cresent Knoll Dr
Current Mailing Address Current Street Address
Raleigh NC 27614 Raleigh NC 27614
City State Zip City State Zip
8. Deed Book No. 8609 Page No. 2404 Provide a copy of the most current deed.
11299 2605
Part B. 12750 1888
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):
Wagoner Homes, Inc chris@wagonerhomes.com
Ti— E-mail Address
a
PO Box 58602
Current Mailing Address
Raleigh NC 27658
City State Zip
Telephone 919-745-7489
Current Street Address
City State Zip
Fax Number.
F2. (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 State Zip
Telephone Fax Number
(b) it 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 State Zip
Telephone 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.
Chris Wagoner Vice President
Type or print name Title or Authority
Sign
-a
Date
a Notary Public of the County of WC1F�
State of North Carolina, hereby certify that dw(5 appeared
personally before me this day and being duly
yss'�w/orrnn acknowledged that t bove form was executed by him.
Witness my hand and notarial seal, this D day of
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