NCC231601_FRO Submitted_20230525

TOWN OF KNIGHTDALE FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
N No person may initiate any land-disturbing activity on one or more acres as covered by the Town
• of Knightdale Unified Development Ordinance before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by Town of
Knightdale, Public Works Department, Stormwater Division. (Please type or print and, if the
question is not applicable, place N/A in the blank.)
Part A.
1. Project Name Stoneriver Subdivision Phases 3-4
2. Location of land-disturbing activity: Wake _ (Town Limits or ETJ)
Hodge Road/Panther Rock Blvd 35.766420° -78.531739°
Highway/Street Latitude Longitude
3. Approximate date land-disturbing activity will commence: Commenced Fall 2021
4. Type of development(residential,commercial, industrial, institutional, etc.):Single Family&Townhomes
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):56.8
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Lance Jackson E-mail Address [e-mail]
Phone# [phone] Cell#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
A.C.Knightdale Investments II,LLC do Amherst Residential,LLC 239-470-0219 [e-mail]
Name(s) Telephone E-mail address
5001 Plaza on the Lake, Suite 200 same
Current Mailing Address Current Street Address
Austin TX 78746 same
City State Zip City State Zip
8. Deed Book No.018637 Page No.01926-01929 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):
A.C. Knightdale Investments II, LLC [e-mail]
Name E-mail Address
5001 Plaza on the Lake, Suite 200 same
Current Mailing Address Current Street Address
Austin TX 78746 same
City State Zip City State Zip
Phone# [phone]

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 Town of Knightdale Erosion and Sedimentation Control Ordinance and/or
Land Disturbance Permit:
Gaines and Co. - Jake Rogers [e-mail]
Name E-mail Address
526 Three Sisters Road same
Current Mailing Address Current Street Address
Knightdale NC 27545 same
City State Zip City State Zip
Phone# [phone]
(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:
A.C.Knightdale Investments II,LLC-Lance Jackson [e-mail]
Name of Registered Agent E-mail Address
5001 Plaza on the Lake, Suite 200 same
Current Mailing Address Current Street Address
Austin TX 78746 same
City State Zip City State Zip
Phone# [phone]
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.
Lance Jackson Authorized Signatory
Type or print name Title or Authority
-A.r-N.--, ssN'tik-- q — — -.a` ..).—‹
Signature Date
da1/4.—.-
I, /--l� n(od .; - , a Notary Public of the County of ��-C�
State of North Carolina, hereby certify that L f_, ry_ '--.7 7 V:N SD 1 J 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 Art-1`( ,20 Z
V
c
Notary
Seal
My commission expires I ' 12. . 2170
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ett• `'` 14 MYCOMMISSION#HH216129
.-1 oci71' EXPIRES:January 12,2026
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