NCC216265_FRO Submitted_20211110

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 Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail andor fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name Sanctuary at Yates Mill Subdivision Lot 90
2. Location of land -disturbing activity: County Wake City or Township
Highway/Street Tealin Ln Latitude 35.782810 Longitude-78.745230
3. Approximate date land -disturbing activity will commence: 10/11/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): .40
6. Amount of fee enclosed: $ 65.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Ward E-mail Address michaelward(a nmwardhomes com
Telephone [phone] Cell # _(919) 669-3005 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Amward Homes of NC Inc _(919) 669-3005
Name Telephone Fax Number
133 Triangle Trade Dr 133 Triangle Trade Dr
Current Mailing Address Current Street Address
Cary NC 27513 Cary NC 27513
City State Zip City State Zip
10. Deed Book No. 018 05 Page No. 02114-02117 Provide a copy of the most current deed.
Part B.
Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
Proprietorship the name of the owner or manager may be listed as the financially responsible party.
Amward Homes of NC Inc michaelwardamwardhomes com
Name E-mail Address
133 Triangle Trade Dr 133 Than le Trade Dr
Current Mailing Address Current Street Address
Cary NC 27513 Cary_ NC
City State Zip City State 27 Zip

Telephone_919) 319-6162 Fax Number
(a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
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
Current Mailing Address
City
State Zip
E-mail Address
Current Street Address
L'Ity
Telephone 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.
Michael Ward
President
Type or print name Title or Authority
10/9/2021
Signature Date
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a Notary Public of the County of _lkllq�':
State of North Carolina, hereby certify that
personalty before me this day and being duly sworappeared
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by him. executedacknowledged that the above form was executed
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