NCC243481_FRO Submitted_20241112

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 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 and/
or fax information unavailable, place N/A in the blank. )
Part A. Heritage point lot 25
1 Project Name
2 Location of land-disturbing activity: CountyWake City or TownshipapeX
Highway/Street. patriOt way Latitude35 . 7400 Longitude __
3. Approximate date land-disturbing activity will commence 1 1 /11 /24
4. Purpose of development (residential, commercial, industrial , institutional, etc.):
residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): ' 92
6 . Amount of fee enclosed: $ 100 The application fee of $100 00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8. 10 ac = $900. 00).
7. Has an erosion and sediment control plan been filed? YesX No Enclosed
8 . Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Darrel Wynne E-mail Address dwynne1965@gmail .001'1'1
Telephone Cell # 9196250897 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LIU YAN SHENG SHI QING 919-599-3389
Name Telephone Fax Number
107 CALLARD RUN
Current Mailing Address Current Street Address
Chapel Hill , NC 27514
City State Zip City State Zip
10. Deed Book No. 1050 Page No. 835 Provide a copy of the most current deed.
Part B.
1 . Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. ) If the company or firm is a sole proprretoiship,
the name of the owner or manager may be listed as the financially responsible party.
Hurst Home Company, LLC annakatherinehurst@gmail . com
Name E-mail Address
6912 Holly Springs Road
Current Mailing Address Current Street Address
Apex, NC , 27523
City State Zip City State Zip
Telephone[phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina give name and street address
of the designated North Carolina Agent:
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 copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Anna Hurst Project Manager
T e or print nameU\P-/YY
Title or Authority
11 /5/24
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natureJ Date
I , 'lj : 11 1- l Fa.rld V , a NotaryPublic of the Countyof Wkc
State of North Carolina, herebycertifythat A /l/) v1 c appeared
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personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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