NCC242769_FRO Submitted_20240909

WWI 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. 110
1. Project Name 27- c F1 �,
2. Location of land-disturbing activity: Jurisdiction `,tiL U. ike. Co • (Wake Co, or Municipality)
Highway/Street 6 2 ri!, iy' Latitude '36.o 375 6 Longitude —?3, 1,69 •3'f
3. Approximate date land-disturbing activity will commence: 6 34/ /i .i
4. Type of developmentesidential commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): •99
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name l,oC(n y n.+Mc,dr) E-mail Address Col is.,/ i h jrr(ii s In 646,6S-&m
Telephone ql1 k4go -006 7 Cell# Fax#
7. Landowner(s) of Record (attach accompanied page to list additional owners):
( ,I £ I1 I y ue_9e r
Name() Telephone Fax or E-mail address
VL1 Qec,1 r"iQ �n Cir Current Mailing Address Current Street Address
t i5h / -C- 274ILI
City // State Zip City State Zip
8. Deed Book No.<O j Q b Page No. al(44- -01115 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):
1-1 0 IA/ 5 r)m l)(i.. A14_5 Lrc.y � WCuSi'cinkoar'.�•eaan
Name Ai
E-mail Address
!(7�l Ai0J"A;a5 Oct) nQ. i� .',fl1
Current Mailing Address Current Street Address
(t.1ei5V\ ,J.C. 11615- e
City ilk State Zip City State Zip
[
Telephone q 436 " I 01 I-7 Fax Number