NCC215410_FRO Submitted_20210929

IV-T WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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
1144.1 It (ARni_,co' 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 The Manors at Waterstone Reserve Lot 18
2. Location of land -disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street 2100 Kinsale Lane Latitude_35.987379 Lon gitude= 78.584093_
3. Approximate date land -disturbing activity will commence: 09/30/2021
4. Type of development (residential, commercial, industrial, institutional, etc.):_Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 0.73
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):
Christopher R. Murray and Mark S. Eubanks
Name(s) Telephone Fax or E-mail address
900 Ridgefield Drive Suite 50 Same as Mailing
Current Mailing Address Current Street Address
_Raleigh NC 27609_ Same as Mailing
City State Zip City State Zip
8. Deed Book No._18614_ Page No._0549 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 Heidel
Name
900 Ridgefield Drive Suite 50_
Current Mailing Address
_Raleigh NC
City State
Tel ephone_919-556-8472
27609
[e-mail]
E-mail Address
_Same as Mailing
Current Street Address
Zip City State
Fax Number
Zip

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
Fax Number
State Zip
(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
Fax Number
State Zip
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 Latval
Treasurer
Type or print n me Title or Authority
08/31 /2021
Signature Date
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I, e_ a Notary Public of the County of WA (1(Q
f North Carolina hereby certify that appeared
State • y y NN
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_
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