NCC241802_FRO Submitted_20240705

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
Countysedimentati Unifiedn co D bb
COUNTY ontrol planevelopment haveOrdinance been completedefore and this approved
form byand an Wake Countyaccepta le Department erosion ofand
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 o ` Q I /V O /i q e
2. Location of land-disturbing activity: Jurisdiction jR(prkE (Wake Co. or Municipality)
Highway/Street f PdTLl_ Aga:*E Latitude 3 S. / /cc ' Longitude — 7g, 6-0 78
3. Approximate date land-disturbing activity will commence: 3— 1 L 4
4. Type of development(residential, commercial, industrial, institutional, etc.): R t. 5 ID�NTI A
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): j 21.5 00 Lei• t-r. V• a $ `I cl c v'e,S
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name r i.),f3E 1=Y ES E-mail Address 1J qa (-elf ; nraq c..i i I.r�rM
Telephone Cell #(9 1 a� 1-9(-5S 55 Fax# �U
7. Landowner(s) of Record (attach accompanied page to list additional owners):
(a =',12. tee RS.N{as' (919)`-91-5855
Name(s) Telephone Fax or E-mail address
S4sME 2823 E�11,112.vt.)G'` R.D
Current Mailing Address Current Street Address
,o, s(G.t-4 N G 27610
City State Zip City State Zip
8. Deed Book No. b i 7 7 09 Page No. 02 Co 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):
QtcB R 1 E.L R,E.` -es q abe c-t e`S d e'Sc,n� rt a i I• con.-1
Name E-r 'ail Addrett
SPcM i-10GE RD
Current Mailing Address Current Street Address
i G i+ N L-- Z./Go/0
City State Zip City State Zip
Telephone 9(9- 65 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.
R.l et-- M-`1�S O LJ N *a-
Type or print name Title or Authority
41-4Q-- 0111k" 2 . t 21
Signature Date
I, vI%G Y‘G l } , a Notary Public of the County of tp�
State of North Carolina, hereby certify that (5 iO \Q,` rik \&( ��Q cy,S appeared
personally before me this day and being duly sworn acknowledged that th above form was ecuted by him.
Witness``y � U
+ •" �al seal, this V5 day of '� /
,\ON. , 20 LLf
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0:. 'NRY . Z Y
0: 0 v Notary
My commission expires v I
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