NCC233013_FRO Submitted_20231006

OWII WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
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COUNTY sedimentationCountyUnified controlev planlopmen haveOrdinanc been completedefore and this approvedform byand an Wake Countyaccepta le Departmenterosion ofand
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 Rockdell Subdivision
2. Location of land-disturbing activity: Jurisdiction Wake Co (Wake Co. or Municipality)
Highway/Street Eagle Rock Road Latitude N35° 45' 54.26" Longitude W78° 24' 04.25"
3 Approximate date land-disturbing activity will commence: May 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): 11.15
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Michael Moss E-mail Address [e-mail]
Telephone [phone] Cell# Same Fax# N/A
7 Landowner(s) of Record (attach accompanied page to list additional owners)
Rockdell, LLC 919-556-3148
Name(s) Telephone Fax or E-mail address
PO Box 610 Same
Current Mailing Address Current Street Address
Youngsville NC 27596 Same
City State Zip City State Zip
8. Deed Book No, 018539 Page No 01261 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):
Rockdell, LLC [e-mail]
Name E-mail Address
PO Box 610 Same
Current Mailing Address Current Street Address
Youngsville NC 27596 Same
City State Zip City State Zip
Telephone [phone] Fax Number n/a

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.
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Type or print name Title or Authority
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Signature Date
V.C.t.ren (fl • T1(1 k-c7 a Notary Public of the County of MOIL
State of North Carolina, hereby certify that m ick ac I R _ YY'iOS5 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�fd day of o. , - h rof 20 a2I
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AARY My commission expires . IaI aoay
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