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
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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
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Seal
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