NCC223810_FRO Submitted_20221114

N-W WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
P=1 SEDIMENTATION POLLUTION CONTROL ACT
WASNo 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
FORTH CAROLIf�A 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 Bailey Meadows Subdivision
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street 5809 Mitchell Mill Rd I Latitude35.878011 Longitude-78.453705
S. Approximate date land -disturbing activity will commence: September 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 9.2 acres
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ronnie Watt E-mail Address [e-mail]
Telephone [phone] Cell # 919-618-5346
Fax # [phone].
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Watt Development Corp.
Name(s)
4213 Cypress Ridge Ct.
Current Mailing Address
Raleigh
City
8. Deed Book No. 018488
Part B.
NC 27616
State Zip
919-618-5346
Telephone
Current Street Address
City State
[e-mail]
Fax or E-mail address
Zip
Page No. 01280 Provide a copy of the most current deed.
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):
Watt Development Corp. [e-mail]
Name E-mail Address
4213 Cypress Ridge Ct.
Current Mailing Address
Raleigh_ NC 27616
City State Zip
Telephone [phone]
Current Street Address
City State Zip
Fax Number_,,c4J_q,:2JZ-1a04 L4A

2. (a) If the Financially Responsible Parry 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:
Name
Current Mailing Address
City
Telephone,
State Zip
E-mail Address
Current Street Address
City State Zip
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
Telephon
E-mail Address
Current Street Address
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.
Ronnie Watt
ti4�—
T or print name
Signature
President -
Title or Authority
-/� Z—
Date
a Notary Public of the County of
State of North Carolina, hereby certify that 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 lday of 20
•��� Notary
RY
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C1, My commission expires