NCC242013_FRO Submitted_20240705

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 Act, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name: Harris Creek Sanitary Sewer Replacement
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
No
2. Location of land-disturbing activity: County: Wake City or Township: Rolesville
Highway/Street: Latitude: 35.890923 Longitude:-78.473695
3. Approximate date land-disturbing activity will commence: 6/28/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: Public Sewer
Replacement
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.40
6. The application fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Marc Chadwick E-mail Address: [e-mail]
Phone: Mobile: [phone]
9. Landowner(s)of Record:
Landowner(s) of Record
Name Email Business Phone Mobile Phone
Charles E. Jones
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
0 Jonesville Rd. Wake Forest NC 27587 0 Jonesville Rd. Wake Forest NC 27587
Name Email Business Phone Mobile Phone
Karen M. &William Davis
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
4932 Upchurch Wake Forest NC 27587 4932 Upchurch Wake Forest NC 27587
Ln. Ln.
Name Email Business Phone Mobile Phone
Terrance Derousse
Physical Address Mailing Address

Street 1 City State Zip Street 1 City State Zip
0 Upchurch Ln. Wake Forest NC 27587 0 Upchurch Ln. Wake Forest NC 27587
Name Email Business Phone Mobile Phone _
Bradley& Michelle Powell
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
4609 Lizzie Creek Wake Forest NC 27587 4609 Lizzie Creek Wake Forest NC 27587
Ct. Ct.
Name Email Business Phone Mobile Phone _
Jennifer N. & Hayes G. Forrester
Physical Address _ Mailing Address _
Street 1 City State Zip Street 1 City State Zip
4929 Upchurch Wake Forest NC 27587 4929 Upchurch Wake Forest NC 27587
Ln. Ln.
Name Email Business Phone Mobile Phone
William &Anne Brown
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
5016 Upchurch Wake Forest NC 27587 5016 Upchurch Wake Forest NC 27587
Ln. Ln.

Part B.
1. Company(ies) who are financially responsible for the land-disturbing activity (Provide a comprehensive list of all
responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is an individual(s), the
name(s) of the owner(s)may be listed as the financially responsible party(ies).
Primary Financially Responsible Party
Company Name Email Business Phone Mobile Phone
Ashton Raleigh Residential LLC [e-mail]
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
900 Ridgefield Raleigh NC 27609 900 Ridgefield Raleigh NC 27609
Dr. Ste. 335 Dr. Ste. 335
Additional Financially Responsible Parties
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the
landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control
plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Registered Agent Information
Name Email Business Phone Mobile Phone
Corporation Service Company [e-mail] 1-800-927-9800
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
2626 Glenwood Raleigh NC 27608 2626 Glenwood Raleigh NC 27608
Ave. Ave.
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina agent who is registered on the NC Secretary of State business registry:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
Engineering/Consulting Firm Information
Name Email Business Phone Mobile Phone
American Engineering bhaertling@american- 919 469-1101
ea.com
Physical Address Mailing Address
Street 1 City State Zip Street 1 City State Zip
4020 Westchase Raleigh NC 27607 4020 Westchase Raleigh NC 27607
Blvd. Blvd.

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water; NSW: Nutrient
Sensitive Waters
2. Was Express Review Requested: Yes
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.