NCC241646_FRO Submitted_20240530

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
WAKECounty 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
NORTH cnaOi.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 Rosinburg Glen: Lots 1 & 7
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Dukes Lake Rd./Rosinburg Rd. Latitude 35.87107723894034 Longitude -78.30258438961991
3. Approximate date land-disturbing activity will commence: June 1, 2024
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 1.76
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Nataleigh Carscaddon E-mail Address [e-mail]
Telephone [phone] Cell # 919-268-9127 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Great Southern Homes, Inc. 803-603-7250 [e-mail]
Name(s) Telephone Fax or E-mail address
90 N. Royal Tower Drive 90 N. Royal Tower Drive
Current Mailing Address Current Street Address
Irmo, SC 29063 Irmo, SC 29063
City State Zip City State Zip
8. Deed Book No.019609 Page No.01022-01024 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):
Great Southern Homes, Inc. [e-mail]
Name E-mail Address
90 N. Royal Tower Drive 90 N. Royal Tower Drive
Current Mailing Address Current Street Address
Irmo, SC 29063 Irmo, SC 29063
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:
Great Southern Homes. Inc. [e-mail]
Name E-mail Address
933 Old Knight Road 933 Old Knight Road
Current Mailing Address Current Street Address
Knightdale, NC 27545 Knightdale. NC 27545
City State Zip City State Zip
Telephone [phone] 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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct. Ste. 200 160 Mine Lake Ct. Ste. 200
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
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.
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Sign t re Date
I, K1 I i s rel \f Cl ZC/ ('1 £Z , a Notary Public of the County of Le,X.I I.1c] to'-
StasotAtti te of •North--6arolina hereby certify that RN c 1 .Tw ( b-)e_ 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_ C. day of 'A101-1 1 , 20 2-t{
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