NCC221976_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20220818

Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCG01 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
. Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage (COC) Number:/ V U-- 2-L- - b
Name of Project: �1' i2- & /y /WS/- y`/
Legally Responsible Organizational Entity:6-Vli�. LLL
PREVIOUS Legally Responsible Individual: rr�� S� 0 ^- y1�1 terra �,J
NEW Legally Responsible Individual: Z1' J'J
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Page 1 of 2

NCGO1 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST RE COMPLETED WITH AN ORIGINAL SIGNATURE (NOS' DIGITAL) [40 CFR '12-7a22 ],
Under penalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
�0 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
This form has been reviewed and is accurate and complete to the best of my knowledge.
ature:
Date
Print Name of Signed:_j
Title:y? �d� (r/` �Q,cJ_e./I e - -
MailingAddress: /Zyt 2-oy le-1 L
Street Address:
Email Address: t2 ` j Le' 6—� �,5 °n t,�vov�>, z cT,-'-
Phone Number: 22.5 - 3 2,3 f
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
Page 2 of 2

FRO Change Request - Remove Jason Marrow & Add Raymond Rinker
Permit #: 2022-00000793
For TOWF Use Only Application #:
Project Name:
Date Received: Acres:
Date Approved: Fees Paid:
TOWN
WAKE
Of
FOREST
LAND DISTURBING (E&SC)
PERMIT APPLICATION, PLAN CHECKLIST, &
FINANCIALLY RESPONSIBLE OWNER (FRO) FORM
NO PERSON MAY INITIATE ANY LAND -DISTURBING ACTIVITY ON 1/2 ACRE OR MORE BEFORE THESE FORMS, FEES, AND AN
EROSION AND SEDIMENTATION CONTROL PLAN SEALED BY A NORTH CAROLINA REGISTERED PROFESSIONAL ENGINEER OR
LANDSCAPE ARCHITECT HAVE BEEN COMPLETED AND APPROVED BY THE TOWN OF WAKE FOREST. MULTIPLE SINGLE
FAMILY LOTS THAT DISTURB MORE THAN A ACRE ALSO REQUIRE A PERMIT AND SHALL FOLLOW THE STANDARD
PROCEDURES OUTLINED BELOW. SEE THE UNIFIED DEVELOPMENT ORDINANCE FOR ADDITIONAL INFORMATION AND FULL
ORDINANCE REGULATIONS.
NOTE. THEAPPUCA77ON FEE OF $500,00 PER ACRE (ROUNDED UP TO THE NEXTACRE I.E.: 1.1 ACRES = 2 ACRES"
$500 = $1,000) IS DUEAT TIME OFSUBMIT►AL. IF FEES ARE NOT SUBMITTED THE PLAN WILL AUTOMATICALLY BE
DISAPPROVED.
DISCLAIMER: TOWN OF WAKE FOREST FEES AND CHARGES ARE SUBJECT TO CHANGE WITHOUT NOTICE.
PLEASE GALL 919-435-9443 TO CONFIRM CURRENT FEES AND CHARGES.
PART A: PROJECT INFORMATION
PROJECT NAME Tyler Garden at Tryon Phase 12 & 14 Lots 1-44
1. TAx PIN NUMBER See attachment
2. ZONING Town of Wake Forest - Residential
3. LocAT1oN/ADDRESS OF TRACTSSp la'ght Acres Way & Latham _Graden Dr - _ - ___

4. SUBDIVISION Tyler Garden at Tryon LOT# 1-44
5. DEED $OOK 2021 PAGE 1500
*PLEASE PROVIDE A COPY OF THE MOST CURRENT DEED
6. PURPOSE OF DEVELOPMENT Residential - Single Family Homes
7. TOTAL NUMBER OF UNITS 44
8. PERCENT IMPERVIOUS SURFACE
9. TOTAL TRACT ACREAGE: 7.19
10. TOTAL ACREAGE DISTURBED (INCLUDING OFF -SITE UTILITIES AND ROADWORK): 3.00
11. AMOUNT OF FEE ENCLOSED:
ROUNDED UP ACREAGE Paid * $500/ACRE = $
CHECK NUMBER
DATE PAID
DISCLAIMER: Town of Wake Forest fees and charges are subject to change without notice. Please call 919-435-
9443 to confirm current fees and charges.
12. PROPERTY OWNER(S) (PROVIDE LIST OF ADDITIONAL PROPERTY OWNERS ON AN ATTACHED SHEET):
NAME Starlight Homes North Carolina, LLC E-MAIL [e-mail]
ADDRESS 5711 Six Forks Rd, Suite 200, Raleigh, NC 27609
PHONE[phone] CELL 919.229.3238
13_ PERSON TO CONTACT SHOULD EROSION AND SEDIMENT CONTROL ISSUES ARISE DURING LAND -DISTURBING ACTIVITY:
NAME Kevin Cheek E-MAIL [e-mail]
ADDRESS 5711 Six Forks Rd, Suite 200, Raleigh, NC 27609
PHONE [phone] CELL 919.414.0360

14. PLANS PREPARED BY Priest Craven & Associates, INC
ADDRESS 3803 Computer Dr., Suite 104, Raleigh, NC 27609
EMAIL BWilliamsPriestCraven.com
PHONE [phone] CELL
15. DOCUMENTS SUBMITTED (SUBMITTER TO PLACE A CHECK MARK IN THE BOX):
FEES ($500 per acre rounded up, due upon 1st review)
FINANCIAL RESPONSIBILITY OWNER FORM
COMPLETED PLAN CHECKLIST
PLANS (to be submitted with construction set)
E&SC CALCULATIONS (1 copy)
STORMWATER CALCULATIONS (1 copy)
MAINTENANCE AND OPERATION AGREEMENT
NCDOT Encroachment/Driveway Permit
DWQ 401 Permit
USACOE 404 Permit
NCGO10000 Permit COC
EROSION & SEDIMENT CONTROL SURETY
APPROXIMATE DATE LAND -DISTURBING, ACTIVITY WILL COMMENCE:
THE SOIL EROSION AND SEDIMENTATION CONTROL PLAN, supporting documents, maps and
computations submitted for the above tract conform to the requirements of all applicable
sections of the Town of Wake Forest Erosion & Sedimentation Control Ordinance outlined in
the U DO.
SIGNATURE TITLE DATE

PART B. FINANCIALLY RESPONSIBLE OWNER (FRO)/PERSONS INFORMATION
1. PERSON(S) OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND -DISTURBING ACTIVITY (PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET):
Starlight Homes North Carolina, LLC - Raymond Rinker [e-mail]
NAME EMAIL
5711 Six Forks Rd, Suite 200,
ADDRESS
Raleigh, NC 27609
CITY STATE ZIP CODE
919.872.0048
PHONE
919.229.3238
CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
NAME
ADDRESS
CITY
PHONE
STATE
CELL
EMAIL
ZIP CODE
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
ADDRESS
CITY STATE ZIP
E-MAIL ADDRESS

PHONE
FAx
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.
Raymond Rinker
NAME
-'IGNXTURE
VP of Land Development
TITLE OR AUTHORITY
/S 2l1Z�
DATE
1, .1 1 U 6,4eav . a Notary Public of the County of
Wn& State of North Carolina, hereby certify that
appeared personally before me this day and being
duly sw rn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 15 day of 20
RRAINE iVETTE RIVET
Notary Public
Wake County. North Carolina
My Commission Expires
My commission expires C6t BD--2D2?�

TOWN of
WAKE FOREST
LAND DISTURBING (E&SQ PERMIT PLAN SUBMITTAL CHECKLIST
(SUBMITTER TO PLACE A CHECK MARK NEXT TO EACH ITEM)
F71. LOCATION/VICINITY MAP
❑ 2. EXISTING AND PROPOSED COUNTOURS, INCLUDING OFFSITE
❑ 3. CLEARLY DELINEATED BOUNDARIES OF LAND DISTURBANCE WITH ACREAGE
❑ 4. SOILS AREA MAP
❑ 5. DRAINAGE AREA MAP
6. EXISTING UTILITY EASEMENTS, STORM DRAINAGE, BASINS, LEVEL SPREADERS
❑ 7. EXISTING LOT LINES, LOT NUMBERS, SURROUNDING PROPERTY OWNERS
g, STREAM CENTERLINES, STREAM BUFFERS, WETLANDS, FLOODPLAINS
❑ g TEMPORARY EROSION CONTROLS TO BE SHOWN ON PLANS:
❑ 1. EROSION CONTROL CALCULATIONS (SEDIMENT BASIN, SEDIMENT TRAP,
SKIMMER, DITCH, ETC...)
2. SKIMMER BASINS REQUIRED FOR DRAINAGE AREA OVER 5 ACRES
❑ 3. IF PAM IS TO BE USED ONSITE FOR ANY APPLICATIONS, CALCULATIONS FOR
APPLICATION RATES AND SPECIFICATIONS MUST BE SHOWN. IN ADDITION,
SOIL TESTS MUST BE TAKEN TO DETERMINE CORRECT SOIL CHARGE AND
PRODUCT TYPE PRIOR TO USE.
❑ 4. CONSTRUCTION ENTRANCE 50 FOOT MINIMUM WITH WOVEN 20 #
TENSILE STRENGTH FABRIC UNDERNEATH
5. SILT FENCE - METAL POSTS WITH WIRE SPACED AT 6 FEET
6. HARDWARE CLOTH OUTLETS (SPECIAL SEDIMENT CONTROL FENCE)
71 7. TREE PROTETION FENCE WITH "DO NOT ENTER TREE PROTECTION AREA"
SIGN IN ENGLISH AND SPANISH
1. REQUIRED AROUND PERIMETER OF
PROPERTY

ii. REQUIRED AT BUFFER ZONES
iii. REQUIRED IN TREE SAVE AREAS (AROUND
DRIP LINE)
❑ 8. DIVERSION DITCHES
❑ g. INLET PROTECTION
❑ 10. EROSION
❑ 11. PERMANENT EROSION/STORMWATER CONTROLS
I. STORMWATER CALCULATIONS, Q PRE, Q POST, %
IMPERVIOUS
ii. PROPOSED STORMWATER EASEMENTS (RECORDED)
iii. MAINTENANCE AND OPERATION AGREEMENT
iv. PROFESSIOANLLY SURVEYED AND ENGINEER STAMPED AS-
BUNLTS OF STORMWATER PONDS/BIO CELLS, LEVEL
SPREADERS, STORM DRAINAGE INVERTS, TOPS, GRATES,
SLOPES, LENGTH, SIZE, ETC...
V. PERMANENT DITCHES WITH MATTING
❑ 10. EROSION PERMIT NOTES: (please add to plans)
1. A LAND DISTURBING (E&SC) PERMIT IS REQUIRED FOR PROJECTS OVER 0.50
ACRE.
IF MULTIPLE LOTS WITH LAND DISTURBANCE OVER 0.50 ACRE TOTAL ARE
EITHER CONTIGUOUS OR NON-CONTIGUOUS IN THE SAME SUBDIVISION, BY
THE SAME BUILDER/OWNER, A LAND DISTURBING PERMIT IS REQUIRED.
THE COST OF THE PLAN REVIEW AND PERMIT IS $500/ACRE ROUNDED UP (1.1
ACRES = 2 ACRES @ $500/ACRE = $1,000). THE FEE IS DUE AT TIME OF PLAN
SUBMITTAL. DEVELOPER IS RESPONSIBLE FOR INFORMING BUILDER OF E&SC
PERMIT REQUIREMENTS ON INDIVIDUAL LOTS.
DISCLAIMER. Town of Wake Forest fees and charges are subject to change
without notice. Please call 919-435-9443 to confirm current fees and charges.
2. IF ADDITIONAL ACREAGE IS ADDED TO AN EXISTING PERMIT REVISED FORMS,
PLANS, AND ANY ADDITIONAL FEES MUST BE SUBMITTED.
3. IF OWNERSHIP OF A PROPERTY HAS CHANGED A REVISED FRO MUST BE
SUBMITTED.
4. IF A PROPERTY IS TAKEN OVER BY THE BANK, THE BANK SHALL CONTACT THE
TOWN AND REPAIR ALL EROSION CONTROL MEASURES TO TOWN/NCDENR
STANDARDS. THEY SHALL ALSO SUBMIT A NEW FRO FORM.
5. IF A PROJECT IS NOT COMPLETE WITHIN TWO YEARS, THE PLANS MUST BE
RENEWED AT $250/ACRE. A REVISED SET OF PLANS MAY BE SUBMITTED 1F
ACREAGE HAS ALREADY BEEN DEVELOPED AND A CERTIFICATE OF OCCUPANY
HAS BEEN ISSUED.

6. AN EROSION PRECONSTRUCTION MEETING MUST BE HELD WITH THE TOWN OF
WAKE FOREST PRIOR TO START OF ANY WORK, INCLUDING INSTALLATION OF
EROSION CONTROL MEASURES, DEMOLITION, CUTTING TREES, AND
GRUBBING.
CALL ENGINEERING AT [phone] TO SET UP A MEETING. ALL PLANS MUST
BE SIGNED AND COPIES RETURNED TO THE TOWN 1 WEEK PRIOR TO
PRECONSTRUCTION MEETING.
7. THE OWNER, GENERAL CONTRACTOR, GRADING COMPANY, AND EROSION
CONTROL INSTALLER MSUT BE PRESENT AT THE PRECONSTRUCITON MEETING.
8. THE E&SC PERMIT WILL BE DISTRIBUTED AT TWS MEETING.
❑ 1i. E&SC CONSTRUCTION SEQUENCE NOTES: (please add to plans)
1. PRIOR TO SCHEDULING THE PRECONSTRUCTION MEETING, THE EROSION AND
SEDIMENT CONTROL SURETY MUST BE SUBMITTED TO THE TOWN OF WAKE
FOREST. THE NCGO10000 CERTIFICATE OF COVERAGE MUST BE OBTAIMED BY
THE PERMITTEE, WHEN APPLICABLE. A COPY OF THE COC MUST BE SUBMITTED
TO THE TOWN.
2. AFTER THE PRECONSTRUCITON MEETING IS HELD, THE CONTRACTOR CAN
INSTALL INITIAL EROSION CONTROL MEASURES ONLY. THIS INCLUDES BUT IS
NOT LIMITED TO CONSTRUCTION ENTRANCE, SILT FENCE, PERIMETER
DIVERSION DITCH, CHECK DAMS (ROCK OR WADDLE TYPE), TREE PROTECTION
FENCE, EXISITNG INLET PROTECTION, SKIMMER SEDIMENT BASINS, AND
SEDIMENT TRAPS. CLEAR ONLY AS NECESSARY TO INSTALL THESE MEASURES.
3. CONTRACTOR IS RESPONSIBLE FOR E&SC WEEKLY INSTALLATION AND
MAINTENANCE LOG INCLUDING DATES OF TEMPORARY/PERMANENT
GROUND COVER, A RAIN GAUGE, COPY OF TOWF SIGNED PLANS ONSITE,
REVISED SIGNED PLANS, NPDES LOG, AND CONSTRUCTION BOX MUST BE
PRESENT AND EASILY ACCESSABLE ONSITE.
4. ONCE MEASURES ARE INSTALLED, CONTRACTOR/FRO TO CALL TOWF FOR AN
INITIAL INSPECTION. IF SITE PASSES INSPECTION, A CERTIFICATE OF
COMPLIANCE WILL BE ISSUED. CONTRACTOR CAN NOW BEING CLEARING,
GRUBBING, AND GRADING.
5. CONTRACTOR TO MAINTAIN ACCESS ROAD FOR EMERGENCIES ATALL TIMES.
6. PHASE PROJECTTO LEAVE AS LITTLE GROUND OPEN AS POSSIBLE.
7. TEMPORARILY SEED, STRAW AND TACK OR HYDROSEED WITHIN 14 DAYS OF
ANY PHASE OF GRADING, INCLUDING SLOPES. SEED BASINS AND DITCHES
IMMEDITEALY AFTER CONSTRUCTION.
S. PRIOR TO REMOVAL OF TEMPORARY MEASURES, TOWN MUST APPROVE
REMOVAL. ALL AREAS ABOVE TEMPORARY MEASURE MUST HAVE 85%
GROUND COVER.
9. THE TOWN OF WAKE FOREST CONSTRUCTION INSPECTOR WILL EVAULATE THE
SITE ATLEAST ONCE A MONTH. A COPY OF THE INSPECTION FORM WILL BE
£MAILED TO THE FRO. THE WEEKLY EROSION LOG AND NPDES LOG MUST BE
ONSITE AND AVAILABLE FOR REVIEW.
10. IF THE SITE IS FOUND OUT OF COMPLIANCE A NOTICE OF VIOLATION WILL BE
ISSUED GIVING THE CONTRACTOR/FRO 7 WORKING DAYS TO REMEDY THE
PROBLEM. IF THE SITUATION IS NOT RESOLVED WITHIN THE TIME PERIOD A
FINE MAY BE ISSUED.
11. IF SEDIMENT LEAVES THE SITE A FINE MAY BE ISSUED UP TO $5,000 PER DAY

PER VIOLATION. IF SEDIMENT ENTERS A BUFFER, STREAM, OR WETLAND
NCDWQ WILL BE NOTIFIED. THEY MAY ISSUE FINES UP TO $25,000 PER DAY PER
VIOLATION.
12. CALL THE TOWN UPON COMPLETION FOR A FINAL EROSION INSPECTION. A
PUNCHLIST MAY BE GENEREATED ADDRESSING ANY REMAINING ITEMS.
THERE MUST BE 85% GROUNDCOVER ON THE ENTIRE SITE PRIOR TO A
CERTIFICATE OF OCCUPANCY. IF THE SITE IS FOUND TO BE IN COMPLIANCE
AN EROSION CERTIFICATE OF COMPLETION WILL BE ISSUED. AFTER THE
COMPLETION OF THE PROJECT, SUBMIT A NOTICE OF TERMINATION TO END
COVERAGE UNDER THE NCG01000 PERMIT.