NCC243372_FRO Submitted_20241031

1111.11.1 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
NOR1 H CAROL!NA
applicable,place N/A in the blank.)
Part A.
1. Project Name Wheeler Residence
2. Location of land-disturbing activity: Jurisdiction Wake (Wake Co.or Municipality)
Highway/Street McSwain PI Latitude 35.838080 Longitude -78.372980
3. Approximate date land-disturbing activity will commence: 09/16/2024
4. Type of development(residential, commercial, industrial, institutional, etc.):
residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.5 ac .89 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name kevin Dillistin E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Richard Wheeler 252-904-9451
Name(s) Telephone Fax or E-mail address
5541 Autry Rd same
Current Mailing Address Current Street Address
Rocky Mount, NC 27803-9229 same
City State Zip City State Zip
8. Deed Book No. 19416 Page No. 1106 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):
Wesbo, Ilc [e-mail]
Name E-mail Address
290 Joe Denton Rd same
Current Mailing Address Current Street Address
Louisburg, NC 27549 same
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:
Robbie Daniels [e-mail]
Name E-mail Address
5321 Ruby Lee Dr same
Current Mailing Address Current Street Address
Wake Forest, NC 27587 same
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:
Kevin S. Dillistin [e-mail]
Name of Registered Agent E-mail Address
280 Joe Denton Rd
Current Mailing Address Current Street Address
Louisburg, NC 27549
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.
Kevin Dillistin Owner
Tye r print am Title o A hority
Ct \
Sig ure ✓ Date
I, c, I-k A 1 , a Notary Public of the County of F-C-v-,K
State of North Carolina, hereby certify that ke c a C)` I\fi S'44 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 I it day of `S ek-,'k , 20 a-1
ot„rttr,i, (
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a Notary
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