NCC215867_FRO Submitted_20211020

I F W. 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
NORTH CAR01INA 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 Collins Property
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
3.
Highway/Street Maude Stewart Rd Latitude 35.5500 Longitude-78.7410
Approximate date land -disturbing activity will commence: -Summer 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): 7.30
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name—Greq Morgan E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
7
Landowner(s) of Record (attach accompanied page to list additional owners):
Morgan Development Company, LLC 919-440-6479
Name(s) Telephone
8524 Walter Myatt Road Same
[e-mail]
Fax or E-mail address
Current Mailing Address Current Street Address
Willow Springs, NC 27592 Same
City State Zip City State Zip
8. Deed Book No. 18190 Page No. 0740 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):
Morgan Development'Company, LLC [e-mail]
Name E-mail Address
8524 Walter Myatt Road Same
Current Mailing Address Current Street Address
Willow Springs, NC 27592 Same
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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:
Greg Morgan
Name of Registered Agent
8524 Walter Myatt Road_
Current Mailing Address
Willow Springs, NC 27592
City State Zip
Telephone [phone]
gregmorgan1000CaDgmail.com
E-mail Address
Same
Current Street Address
Same
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.
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Type or"print namd Title or Au hority
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Signatur Date
I, �►Iy ,, L. y r,..c 3, r _, a Notary Public of the County of App*e,
State of North Carolina, hereby certify that appeared
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 21
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