NCC232447_FRO Submitted_20230815

"WI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
un Development co be b
COUNTY sedimentationContyU ified control planevelopmen haveOrdinan been completedefor and this approvedform byand Wakean Countyaccepta le Departmenterosion ofand
NUIt"111(:,\It()IIN,\ 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 nf) D(6 Q (ID t n LS. y t-0-1- 2
2. Location of land-disturbing activity: Jurisdiction C'ti CL- .Q� (Wake Co. or Municipality)
Highway/Street\ fra u SYVI 1 1 k Latitude S c, S S d S l Longitude ` 7 g . `7 `f 0 A-
3. Approximate date land-disturbing activity will commence: S // S/c9o; _3
4. Type of development (residential, commercial, industrial, institutional, etc.):)(Q S t OuLt711,-0. 1
5. Total acreage - disturbed or uncovered (including off-site utilities and borrow/waste
areas): O , G 7
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ---Ri 4 e E-mailiaiP, I Address ta QI 9-0tlQ QsAfaVlk.. . Q.,yr\
Telephone Cell# CO q• ()) - (p j_77 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
11,e iti S L.),/ry L 0 i 1 I g "5 4 t1 - 1
Name(s) Telephone Fax or E-mail address
SDI S4 `r-�ias - 4 .
urrent Mailing Address Current Street Address
City State Zip 11 City State Zip
8. Deed Book No. / q 0 S i lD
Page No. 7 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):
)( ICE a Y c 9_r1 9- d{-Q,R sic)o► ylk s .(',b ill
Name I Email Address
SD 1 s;x r"or k_S SQ 9_
rrent Mailing Addressr._7 )
Current Street Address
OLlikS) ., NJ e. . 1-1,6 1
City State /n� Zip City State Zip
Telephone � 1 C ,6 Uk-i- 9dX g 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.
--?
-p V , 1 Ct it
Type or print name Title or Authority
VA a/(4- 0
Si nature Date
I, T�,11l-Q S /1 I i2(114E4 a Notary Public of the County of C/J
State of North Carolina, hereby certify that \k y (L bQjZ_i i appeared
personally before me this day and being duly sworn acnowledbed that the above form was executed by him.
/ r�
Witness my hand and notarial seal, this / day of /- i , , 20 c
THEI A.TREFFTZS otary
ary Public
Wake County,North Carolina My commission expires D D y
My Commission Expires /
March 6,2024