NCC241498_FRO Submitted_20240516

11.1111111 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
NORTH�..,R�,,,�_, 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 1608 Pond Spring
2. Location of land-disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Pond Spring Dr Latitude 35.778740 Longitude -78.426860
3. Approximate date land-disturbing activity will commence: 5/15/2024
Residential
4. Type of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.25
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Marc Segre rrock.com
E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Craig and Brenda Herb 919-368-3973
Name(s) Telephone Fax or E-mail address
1620 Pond 1620 Pond Spring Dr
Current Mailing Address Current Street Address
Spring Dr Wendell, NC 27591 Wendell NC 27591
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 responsible parties on an attached sheet. Include requested information):
Marc Segre [e-mail]
Name E-mail Address
1608 Pond Spring Dr 1608 Pond Spring Dr
Current Mailing Address Current Street Address
Wendell, NC 27591 Wndel, NC 27591
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.
Marc Segre Builder
Type or print name Title or Authority
,V-L //c/ 24
Signature Date
I, q eJ G(VLl(/ 1- • Sarrnife/tS , a Notary Public of the County of W a
State of North Carolina, hereby certify that MO t C Sec r e appeared
personally before me this day and being duly sworn acknowledged thaat the above form was executed by him.
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Witness my hand and notarial seal, this l5 day of A1.41 I , 20
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