NCC230080_FRO Submitted_20230112

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
YYT County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have. been completed and approvedby Wake County Department of
NORTH CflRO[..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 Lot 7 Enchanted.Oaks
Municipality) or Co.. Co Wake
2. Location of land -disturbing activity: Jurisdiction Wake�� (-
Highway/Street Bent Leaf Dr Latitude 35.7Q2187 Longitude-78.703159
3. Approximate date.land-disturbing activity will commence:
12/16/22
4.. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. , Total acreage disturbed, or uncovered ' (inclu ing off -site utilities and , borrow/waste
areas): 0.95
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matthew Kerul E-mail [e-mail]
Telephone [phone] Cell # 770-286-1013 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Bent Leaf Development 91975122-6281
Name(s) Telephone Fax or E-mail address
8232 Pritchett Farm Ln 8232 (,Pritchett Farm Ln
Current Mailing Address Current Street Address
Raleigh NC. 27606 Raleigh NC 27606
City State Zip City. State Zip
8. Deed Book No. 17999 Page No. 0", 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 ail responsible parties on an attar ed sheet, Include requested information):'
Bent Leaf Development ckiger@cimginc:com
Name E-mail Address
8232 Pritchett Farm Ln 8232 Pritchett Farm Ln
Current Mailing Address Current Street Address
Raleigh NC 27546 Raleigh NC 27606
City State Zip City. State Zip
Telephone [phone] 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 Waite 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) 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 E-snail 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 l=inancially 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 nformation provided herein.
COAL J. )�166
TyM name Title ot Authority -
QZQ�.J.
Signature Date
--- - -- ----- `--------ee---------------------------
I, J Ck 1 a Notary Public of the County of
State of North Carolina, hereby certify. that 1 _ aY Yt � aY appeared
personally before me this day and being duly sworn acknowledged tha the above form was executed by him.
Witness my hand and notarial seal, this - ice,..— day of _.�O�IrZ cL0. 202 3
SCq ►y��`�
���.'�P•• •-•.�,'N��,�� Notary
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20 _ My co mission expires
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