NCC231873_FRO Submitted_20230615

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
. T No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County Unified Developplament d be e o sedimentation control n haveOr beeninance completedefor and this approvedform byand Wan ake Countyacceptabl Departmentersion ofand
COUNTY
NORTH CAROLINA 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 Hills at Rockbridge
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Grasshopper Rd Latitude 35.739134 Longitude -78.459180
3. Approximate date land-disturbing activity will commence: June 2021
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 4.8
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Bobby Hilgoe
Name E-mail Address [e-mail]
Telephone [phone] Cell# -. Fax#
7, Landowner(s)of Record (attach accompanied page to list additional owners):
STAFFORD LAND COMPANY INC [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
246 VALLEYFIELD LN
Current Mailing Address Current Street Address
SOUTHERN PINES NC 28387
City State Zip City State Zip
8. Deed Book No. 018464 Page No. 00001 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):
Bobby Hilgoe [e-mail]
Name E-mail Address
900 Perimeter Park Dr, Suite E (}C6 1
Current Mailing Address Current Street Address
Morrisville, NC 27560 1�, N L760 I
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:
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Typeprint name Title or Authority
or
°11/(j(
) I z.02-
Signat Date
I, i ck-VN:eA (ct> , a Notary Public of the County of JO L a
State of North Carolina, hereby certify that +gyp 'C R� yip yJ, l- L' oe appeared
personally before me this day and being duly sworn acknowledged that the above form was ecuted by him.
Witness my hand and notarial seal, this o� day of l��o , 20
Daniel Gray Notary
Seal C311(
Notary Public My commission expires t
Johnston County, NC