NCC211751_MODIFICATION Supporting Documents_20220325 (2)

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WTNo 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
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROLIN 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 Poplar Creek Village - Ph IV
2. Location of land -disturbing activity: Jurisdiction Wake Co. (Wake Co. or Municipality)
Highway/Street Clifton Road Latitude 35.761608 Longitude-78.497782
3. Approximate date land -disturbing activity will commence: January 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acfTege disturbed or uncovered (including off -site utilities and borrow/waste
areas):
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name
Geoff Reichett E-mail Address [e-mail]
919-353-1928
Telephone Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Clayton Properties Group, Inc
Name(s) Telephone Fax or E-mail address
2521 Schieffelin Road
Current Mailing Address Current Street Address
Apex NC 27502
City State Zip City State Zip
8. Deed Book No. 18352 Page No. 1140 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):
Clayton Properties Group, Inc [e-mail]
Name E-mail Address
2521 Schieffelin Road
Current Mailing Address Current Street Address
Apex NC 27502
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:
NIA
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:
Moore & Alphin [e-mail]
Name of Registered Agent E-mail Address
3733 National Dr, Suite 100
Current Mailing Address Current Street Address
Raleigh, NC 27612
City State Zip City State Zip
Telephone [phone]
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.
Adam Speiran
Type or print name
Signature
Assistant Secretary
Title or Authority
I'ZI t Z.t
Dat6
I, V-iy t, 6MtA Park--- a Notary Public of the County of k"Ilf,
State of North Carolina, hereby certify that P&M gp ra'n 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 �COVIOCr , 20 Z[- A"
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KtMbFttY BARK t� 7-
Notary Public, North Carolina My commission expires �'t0'_
Wake County
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