NCC240798_FRO Submitted_20240319

OP. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAK E No 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
,.,,�.�,t,,,� 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 Kreitlow Residence
2. Location of land-disturbingactivity: Jurisdiction Wake County
y (Wake Co. or Municipality)
Highway/Street 4925 Foxridge Drive _Latitude 35.7035 Longitude -78.7220
3. Approximate date land-disturbing activity will commence: March 25, 2024
4. Type of development(residential, commercial, industrial, institutional,etc.): single family residential
5. Total acres a disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.99 acre
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Adam Marlow, Don Pegram E-mail Address [e-mail], [e-mail]
Telephone [phone] Cell# 919 616 2392 Fax#
7. Landowner(s)of Record(attach accompanied page to list additional owners):
Kelly & Kimberly Kreitlow, Trustees 919-605-4999 [e-mail]
Name(s) Telephone Fax or E-mail address
710 Eastridge Drive Same
Current Mailing Address Current Street Address
Apex NC 27539
City State Zip City State Zip
8. Deed Book No 019257 Page No. 1945 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):
Kelly and Kimberly Kreitlow [e-mail]
Name E-mail Address
710 Eastridge Drive same
Current Mailing Address Current Street Address
Apex NC 27539 same •
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:
N/A
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:
N/A
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.
I�c1ll� �trej �La Owner
Type or print me Title or Authority
2/ Zy
Signature Date
I, L O-Q ) (IJ VCLL , a Notary Public of the County of (VI k
._
State of North Carolina, hereby certify that ,l � (1,�,� appeared
personally before me this day and being duly sworn acknowledg d that the above form was executed by him.
Witness my hand and notarial seal, this 1 day of Rhfuctay ,20 1L1
L4Q,b(. ratA<CL
Notary
Seal )
My commission expirespc -r&O
LAUREN M KAY
Notary Public
Wake Co., North Carolina
My Commission Expires April 20,2027