NCC233747_FRO Submitted_20231220

IWO WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
Countysedimentati Unified co Development be b
COUNTY on ntrol plan haveOrdinance been completedefor and this approvedform byand an Wake Countyaccepta le Departmenterosion ofand
,,.F<<�„ ,���� 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 Pleasant Union Property
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co. or Municipality)
Highway/Street Pleasant Union Church Latitude 35.57'34.0047 Longitude -78.40'13.3756
Road
3. Approximate date land-disturbing activity will commence: 01/01/2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Residentail
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 12.3
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
John Teel
Name E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Philip Ellis Co-Trustee Ray, Karen Inez Co-Trustee
Name(s) Telephone Fax or E-mail address
3401 Noel Ct
Current Mailing Address Current Street Address
Raleigh NC 27607
City State Zip City State Zip
8. Deed Book No. 10-E- Page No. 865 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):
Arcaterra Land, LLC [e-mail]
Name E-mail Address
4515 Falls of Neuse Road Suite 175 4515 Falls of Neuse Road Suite 175
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
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 a Corporation, givee name and street address of the Registered Ag�entt:/� �� �J
I1G,7t'I �Q/� �i/ /-�� y'(. Iii/�7'��C!�D /6Re.. 4,/¢K . C�!/`mil
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
ail -,41f G 2gD
City State q Zip City State Zip
Telephone 6 1 " b 3 - ! 9 97 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 ny change in the information provided herein.
fliC !Jr t�
Type or int me Title or Authori
IA` 7 '7 ��
Signat Date
I, icl-LLau S , a Notary Public of the County of WYcl-VI✓
State of North Carolina, hereby certify that f\AV 2 (VI rPrL.r)CN►q-(J`, 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 1'7day , 20
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pSARY N• My commission expires
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