NCC233244_FRO Submitted_20231031

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
\'VAKE County 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
= AF )1 tk� 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 Camberly Lot 7
2 Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Gentry Dr. Latitude 35-990233* Longitude -78.574209*
3. Approximate date land-disturbing activity will commence: 10-01 -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): 0.75
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Kevin Nunn E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Southern Heritage Residential, LLC 919-796-9368 [e-mail]
Name(s) Telephone Fax or E-mail address
5204 Moneta Ln 5204 Moneta Ln
Current Mailing Address Current Street Address
Apex NC 27539 Apex NC 27539
City State Zip City State Zip
8. Deed Book No. 2018 Page No. 1487-1488 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):
Southern Heritage Residential, LLC [e-mail]
Name E-mail Address
5204 Moneta Ln 5204 Moneta Ln
Current Mailing Address Current Street Address
Apex NC 27539 Apex NC 27539
City _ _ — State Zip City State Zip
Telephone [phone] Fax Number
_
1

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 Pemiit:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A _ _ N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
Southern Heritage Residential, LLC
Kevin Nunn [e-mail]
Name of Registered Agent E-mail Address
5204 Moneta Ln 5204 Moneta Ln
Current Mailing Address Current Street Address
Apex NC 27539 Apex NC 27539
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.
Southern Heritage Residential, LLC
Kevin Nunn President
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