NCC233729_FRO Submitted_20231219

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
w Development de bbo
COUNTY sedimentationCountyUnified controlv planlopmen haveOr beeninanc completedefore and this approvedform byand an Wake Countyaccepta le Departmenter sion ofand
NOR.I (.AWL NA 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 4213 Grahamstone Road Raleigh, NC 27610 (RGA 381 Middleton)
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Grahamstone Rd Latitude 35.715883 Longitude -78.516928
3. Approximate date land-disturbing activity will commence: 12/21/2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.72
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameJonathon Haper E-mail [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Lee R. Middleton and Nancy J. Middleton 908-507-6415
Name(s) Telephone Fax or E-mail address
1102 Barley Sheaf Road Same as mailing
Current Mailing Address Current Street Address
Flemington, NJ 08822 Same as mailing
City State Zip City State Zip
8. Deed Book No.017462 Page No.01267 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):
The Drees Homes Company [e-mail]
Name E-mail Address
8521 Six Forks Rd. Suite 500
Current Mailing Address Current Street Address
Raleigh, NC 27615
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:
Reginald B. Gillespie Jr. nhammondsta'�,dreeshomes.com
Name of Registered Agent E-mail Address
4600 Marriott Drive Suite 400 Same as mailing
Current Mailing Address Current Street Address
Raleigh, NC 27612 Same as mailing
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.
Jonathon Haper General Manager
Type or rint name Title or Authority
12.411 /�3
Sign u Date
I,WOS5v,_ � c1&L, , a Notary Public of the County of NI K
State of North Carolina, hereby certify that 70(1 ig Racc-QS— 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 , 202..S
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Seal �, '••• 1f1......... g/27/28
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