NCC223593_FRO Submitted_20221025

=�w WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P:Tl 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
NOR, I CAROI INA 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 McKenzie Meadows Subdivision (Lots 6-13,175-178,184-188,237-240,289-292,232-
236,154-156,159-174,157)
2. Location of land -disturbing activity: Jurisdiction . Wendell (Wake Co. or Municipality)
Highway/Street Old Zebulon Road
Latitude 35.797161
3. Approximate date land -disturbing activity will commence: 712022
Longitude-78.353584
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 63.0
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chris Raughley E-mail [e-mail]
Telephone
Cell # 919-795-9347 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
McKenzie Meadows Developers LLC
Name(s)
1122 Oberlin Road Suite 226
Current Mailing Address
[phone]
Telephone
carolinalandgrou p@outlook. corn
Fax or E-mail address
1122 Oberlin Road Suite 226
Current Street Address
Raleigh NC 27605 Raleigh NC 27605
City State Zip City State Zip
8. Deed Book No. 018596 Page No. 01496 Provide a copy of the most current deed.
Part B.
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):
Pulte Home Company, LLC [e-mail]
Name E-mail Address
1225 Crescent Green Dr, Ste 250
Current Mailing Address
Cary
City
IC 27518
State Zip
1225 Crescent Green Dr, Ste 250
Current Street Address
Cary NC 27518
City State Zip
Telephone (919)_795-9347 _ __ 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 [wand
Disturbance Permit:
Chris Rau hle
Name
1225 Crescent Green Dr, Ste 250
Current Mailing Address
[e-mail]
E-mail Address
1225 Crescent Green Dr, Ste 250
Current Street Address
Cary NC 27518 Cary NC 27518
City State Zip City State Zip
Telephone [phone] 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
E-mail 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.
Type or print name
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Signature
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Title or Authority
(� 22
Date
I, f UV r n ncL , a Notary Public of the County of VI/61 k2
State of North Carolina, hereby certify that ('& __ (}h i..� ✓a appeared
personally before me this day and being duly sworn acknowledged that tM above f6rm was executed by him.
Witness my hand and notarial seal, this day of jVdj4 20`LL
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Seal
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Notary
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