NCC240348_FRO Submitted_20240209

ICWI WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
W� No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
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
NQlii ti CAlti)L 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.
Lot 18 Sanctuary at Lake Wheeler
1. Project Name
2. Location of land-disturbingactivity: Jurisdiction Wake Co.
Y (Wake Co. or Municipality)
Highway/Street 2816 Theresa Eileen Way Latitude 35.7049492 Longitude -78.6915808
3. Approximate date land-disturbing activity will commence: 3/15/24
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential -
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):_ 0.58
—
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name James Dentin [e-mail]
E-mail Address
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Future Homes by Jim 919-363-4111
Thompson,Inc
Name(s) Telephone Fax or E-mail address
1105 Classic Road Same as Mailing
Current Mailing Address Current Street Address
Apex,NC 7539
City State Zip City State Zip
019493 00203
8. Deed Book No. Page No. 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):
Future Homes by Jim
Thompson, Inc
Name E-mail Address
1105 Classic Road Same
Current Mailing Address Current Street Address
Apex NC 27539
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Resp nsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive a y 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 opy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Jim Thompson [e-mail]
Name of Registered Agent E-mail Address
1105 Classic Road
same
Current Mailing Address Current Street Address
Apex NC 27539
City State Zip City State Zip
919-363-4111
Telephone Fax Number
The above information is tru 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 nct 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.
Jim Thompson President
Type or print name Title or Authority
1/11/2024
Signature Date
I'
I, - 1(\ApeC'1U IDeuv 11 S , a Notary Public of the County of \NI P_i
State of North Carolina, hereby certify that Z t m M1 crnpSo r) appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
41
Witness my hand and notarial seal, this day of rug,t-� , 20 ahl--
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