NCC231605_FRO Submitted_20230526

1:11.11. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo 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
.oiirri :�H< DNA 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 Acorn Creek
2. Location of land-disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Acorn Creek Lane Latitude 35°46'43.2"N Longitude 78°25'37.9"W
3. Approximate date land-disturbing activity will commence: January 1, 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.60
6. Person to contact/JM6
should erosion
_a and sedim-geent control issues arise during land-disturbing activity: /'� /�/� _ s�
Name / 1 &- E-mail Address( t6- Y- 'L O c til
Telephone AIM- Cell# 7/'3a3 IL A`* co `
7. Lanndoownnejr(s) of Record (attach accompanied page to list additional owners):
e6 is 34 %?Cl 73
Name(s) Telephone Fax or E-mail address
( 73 ' 4COre (- M-NE
Current Mailing Address Current Street Address
t) eN OZ-c.L, AJC 2,-75 71
City State Zip City State Zip
8. Deed Book No. 018456 Page No. 01403 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 respons. e parties on an attached sheet. Include requested information):
_11,0-MFH6
Name E-mail Address
Cie' 1133 /co91 c e
Current Mailing Address Current Street Address
tIJ s u_ AA_ 2`7 7
Ci� State Zip City State Zip
Telephone W' ?.t 3773ax 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 Land
Disturba ce P r 't:
Nam 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 Cor
Nam ration, give name and street address of the Registered Agent:
Ai A--
e of i g ster ed 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.
eiA/ Cr- /Je6 Z4'Vc WL7z.
Type Qr print name Title or Authority
-, /0/1/2-4 Z-Z---
Signature Date
I, 3aSt Va Git,f(Avkt+,10k_ , a Notary Public of the County of W
State of North Carolina, hereby certify that C VC i t v rN appeared
personally before me this day and being duly sworn acknowletedge t the above form was executed by him.
Witness my hand and notarial seal, this 1 1 day of lit t'6 __v-- , 20 Ak
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