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NCC220171_FRO Submitted_20220111
VVAKE COUNTY NURIH CA RULINA Part A. 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 County Unified Development Ordinance before this form and an acceptable erosion and 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 NIA in the blank.) Project Name S4 Jackson Manor Lot #38 2. Location of land -disturbing activity: Jurisdiction AAG CWNA' (Wake Co. or Municipality) HighwaylStreet 3 LN ✓Latitude L�o,,n�git�ude 3. Approximate date land -disturbing` activity will commence: -e' �nZDZ I 4. Type of development (residential, commercial, industrial, institutional, etc.): 5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste areas):_ D . b 6. Person to contactshoulderosion and sediment control issues arise during land -disturbing activity: Air �n E-mail Address M �eVS91\ D 10 W Name i((lc-v Telephone Cell # Hai j0 ' �� L Fax # 7. Landowner(s) of Record (attach accompanied page to list additional owners): a 111611. n i otoA) he-, 11. Name(s) Telephone Fax or E-mail address I D ��ncG,��sk ,r ' A tA& Current Mailing Address Current Street Address 11/y f� So 0\ el City State Zip City State Zip 8. Deed Book No. U fJ (� Page No. 00-6" !� 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 Lnsive list of all responsible parties on an attached sheet. Include requested information): son fG saw D t d GJ i\G, Name E-mail Address Current Mailing Address Current Street Address O c, City I State , y Zip ` Telephone l r © Ll City Fax Number State 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 any matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land Disturbance Permit: kc, a 1 n N\arv�ur\ b bl Je Je o&a ion . eom Narhe E-mail Address Current POlailing Address ke. �&6s - n L 2 S$1 City State Zip Telephone 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: Name of Registered Agent Current Mailing Address City Telephone E-mail Address Current Street Address State Zip 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. �,1cl,ya P. Asa ©one/ Type or print nam Title or Authority jigature Date -------------------------------------------------------------------------------------------------------------------------- 1 a Notary Public of the County of Lc� wt�}erl ctvts�- State of North Carolina, hereby certify that i (_kVd , 1� n s G vL 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 R5^P' day of ©Glob""- , 20 X1 ,p.%L BOG Seal tvQ;' gyp'[ A R y v = C) �G G , PU%3 AND`\ &L�P r__ (nary My commission expires 10%� lacaa�