NCC232324_FRO Submitted_20230803

CP" WAKE COUNTY 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 Wake
WAKECounty 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
�,� Environmental Services, Water Quality Division, (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name 7116 Spring Ridge Rd
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Spring Ridge Rd -Latitude 35.730167 Longitude -78.751218
3. Approximate date land-disturbing activity will commence: April 1st,2023
4. Type of development(residential, commercial, industrial, institutional,etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):_4.00 ac.
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rodney McLamb E-mail Address [e-mail]
Telephone [phone] Cell# [phone] Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Foxwin Properties, LLC [phone] [e-mail]
Name(s) Telephone Fax or E-mail address
4906 Gann Trail 4906 Gann Trail
Current Mailing Address Current Street Address
Raleigh, NC 27612-3682 Raleigh,NC 27612-3682
City State Zip City State Zip
8. Deed Book No.018555 Page No. 02029-02030 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):
Foxwin Properties, LLC [e-mail]
Name E-mail Address
4906 Gann Trail 4906 Gann Trail
Current Mailing Address Current Street Address
Raleigh, NC 27612-3682 Raleigh, NC 27612-3682
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:
Christopher E Blum [e-mail]
Name of Registered Agent E-mail Address
4906 Gann Trail 4906 Gann Trail
Current Mailing Address Current Street Address
Raleigh, NC 27612-3682 Raleigh, NC 27612-3682
City State Zip City State Zip
Telephone [phone] 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.
Christopher E Blum Manager
Type or print name Title or Authority
7—13-2v43
Signature Date
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n �*� a Notary Public of the County of r _
State of North Carolina, hereby certify that N 15iill" 71"A°'`) ul-A 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 �3 day of , J( 17 ,202-7-j
Notary
Seal
ROMMEL SIM4N My commission expires
NOTARY PUBLIC
KE ,NC
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