NCC215390_FRO Submitted_20210929

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WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLAJTION CONTROL ACT Hyp
�-0����No erson ma initiate an land-disturbin activit on on or m reac as covetheWake
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WAKECounty 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
CW Sao
1. Project Name The Manors at Waterstone Reserve Lot 2
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street 2361 Ballywater Lea Way Latitude_35.989916 Longitude_ 78.574721
3. Approximate date land -disturbing activity will commence: 08/30/2021
4. Type of development (residential, commercial, industrial, institutional, etc.):_Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.80
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andy Hurst E-mail [e-mail]
Telephone [phone] Cell # 919-389-1431 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Homestead Building Company
Name(s)
900 Ridgefield Dr. Suite 50
Current Mailing Address
Raleigh NC NC 27609_
Telephone
Same as Mailing
Current Street Address
Same as Maili
rax or c-mau aaaress
City State Zip City State
8. Deed Book No._18459_ Page No._2152 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):
John Heide[
Name
P.O. Box 848
Current Mailing Address
_Wake Forest N
City
Tel e p h o n e_919-556-847
[e-mail]
E-mail Address
_900 Ridgefield Sr. Suite 50
Current Street Address
Zip
C 27588 Raleigh NC 27609
State Zip City State Zip
2 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 an y
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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:
_John H. Heidel
Name of Registered Agent
_P.O. Box 848.
Current Mailing Address
_Wake Forest NC 27588
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
same as mailing
Current Street Address
same as mailing
City State Zip
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.
Robert Latvala
Type or print me
Signature
Treasurer
Title or Authority
10/29/2020
Date
, a Notary Public of the County of VJ-
State of North Carolina, hereby certify thatappeared
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 2.1
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