NCC232870_FRO Submitted_20230922

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
V VIE Cfied em Ordinance before
COUNTY sedimentation controlDev planlop ent have been completed andthis approvedform byand an Wake Countyacceptable Departerosionmentand of
NORTH CAROLINA 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 Wexford Reserve Lot 59
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Wexford Waters Lane Latitude 35-991313 Longitude -78.547336
3. Approximate date land-disturbing activity will commence: 10/2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.29
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chris Elliott E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Wilks Builders Inc. [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
4213 Worley Dr. 4213 Worley Dr.
Current Mailing Address Current Street Address
Raleigh NC 27613 Raleigh NC 27613
City State Zip City State Zip
8. Deed Book No. 019246 Page No. 02092 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):
Wilks Builders Inc. [e-mail]
Name E-mail Address
4213 Worley Dr. 4213 Worley Dr.
Current Mailing Address Current Street Address
Raleigh NC 27613 Raleigh NC 27613
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.
Neil Wilks Owner
Type or print na Title or Authority
/,:�j �--� 6/29/23
Signatu Date
I, littnAt liftwo4 131.4fit , a Notary Public of the County of WitIl.t
State of North Carolina, hereby certify that ,;LY�. WitILS 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 + - , 20 2,5
Notary
w .,. 7,} st My Commission expires --3QMy COCIritt,i
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