NCC224075_FRO Submitted_20221213

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 Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place N/A in the blank.)
Part A. The Reserve at Blake Farm Expansion
1. Project Name p
2. Location of land -disturbing activity: County Pender City or Township Wilmington
Highway/Street US-17/ Blake Farm Blvd. Latitude 340 19' 36.9" N Longitude 770 45' 46.9" W
3. Approximate date land -disturbing activity will commence: 12/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.9
6. Amount of fee enclosed: $ 400 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Taylor H011ingshead, PE E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Blake Farm Apartments II, LLC 919-926-1872 919-573-9365
Name Telephone Fax Number
3605 Glenwood Ave. Suite 445 3605 Glenwood Ave. Suite 445
Current Mailing Address Current Street Address
Raleigh, NC 27612 Raleigh, NC 27612
City State Zip City State Zip
10. Deed Book No. 4775 Page No. 1485-1486 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
BLAKE FARM APARTMENTS II, LLC
Name E-mail Address
3605 Glenwood Ave. Suite 445 3605 Glenwood Ave. Suite 445
Current Mailing Address Current Street Address
Raleigh, NC 27612 Raleigh, NC 27612
City State Zip City State Zip
Telephone [phone] Fax Number 919-573-9365

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
William M. McClatchey, Jr. Manager
Type or print name
Signature
Title or Authority
-zAII,z2
Date
{ A14N a Notary Public of the County of Wake
State of North Carolina, hereby certify that t►`�>> 11112 /� ¢(,IA'�i. �,Q� appeared
personally before me this day and being duly sworn acknowledged that thd aabove form was
executed by him. g
Witness my hand and notarial seal, this u % day of V4 20 u'
gatt't4 j _Auv�
BARRY D. MANN Notary
Se I NOTARY PUBLIC
WAKE COUNTY, N.C.
My Commission Expires 03-17-2024 My commission expires 0� kz 12.(+