NCC231739_FRO Submitted_20230608

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
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
YL1R1N CAROL INA Environmental Services. Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Norwood Ridge Lots 8, 13, 16 & 17
1. Project Name
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Lot 8 35 938848 Lot 8.-78 657476
Norwood Ridge Drive/ Lot 13 35939968 Lot 13..78.656510
Crest Court Lot 16-35941610 ot6:16654676
Highway/StreetCanyonLatitude Lot 17 35941610 Longitude_ Lot 1T-78854611
3. Approximate date land-disturbing activity will commence: 6/1/2023
4. Type of development(residential, commercial, industrial, institutional, etc.). Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 3.734 Acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jason Mathena E-mail Address [e-mail]
Telephone _ Cell# 919-616-9534 Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Arcaterra Land LLC 919-606-6587 [e-mail]
Name(s) Telephone Fax or E-mail address
8540 Colonnade Center Dr., Ste 105 8540 Colonnade Center Dr., Ste 105
Current Mailing Address Current Street Address
Raleigh, NC 27615-3052 Raleigh, NC 27615-3052
City State Zip City State Zip
8. Deed Book No. 18575 Page No. 1986 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 information)
Blue Heron Signatures Homes LLC jason.mathena©blueheronhomesnc.com
Name E-mail Address
8540 Colonnade Center Dr., Ste 103 8540 Colonnade Center Dr., Ste 103
Current Mailing Address Current Street Address
Raleigh, NC 27615-3052 Raleigh, NC 27615-3052
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 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) 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-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.
Jason Mathena U I C>-I'` CAA S1^-'LkCJ''`
Ty o rint na Title or Authority
/22 / 3 - -
Sig urepre\
Date
I, 2 Ol1—Vl t k Ivl \CQJ- , a Notary Public of the County of Wc-i L
State of North Carolina, hereby certify that , --r ,-A \''l(4 ` , Y- i appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this ' ' day of (V\(1. ` , 20 3
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