NCC243527_FRO Submitted_20241115

W. WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
Y Y1�1 No person may initiate any land-disturbing activity on one or more acres as covered byr the Wake
County 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 i
��„�.,.,,�„n�,,, n 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 Shinleaf Estates Waterline Extension to Offsite Well
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Route 98 Latitude 35.9843 Longitude-76,6498
3, Approximate date land-disturbing activity will commence: 11-5-2024
4. Type of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):3.70 Ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chad Brinlev E-mail Address chad cahrinlevsgradina.com
Telephone [phone] Cell# N/A Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Ammons Property Two, LLC 919-669-9268 N/A
Name(s) Telephone Fax or E-mail address
8368 Six Forks Road,Suite 204 8368 Six Forks Road.Suite 204
Current Mailing Address Current Street Address
Raleigh NC 27615 Raleigh NC 27615
City State Zip City State Zip
8. Deed Book No.019622 Page No.01942 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):
Blantons Creek Developers. LLC chadc brinlevsgradina,com
Name E-mail Address
PO Box 97487 8368 Six Forks Rd,Suite 204
Current Mailing Address Current Street Address
Raleigh NC 27624 Raleigh NC 27624
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
IE
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:
NiA
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.
CITA&ton letg NArt al CO; Og t ff,/26 r 1 i1/61
Type or printname Title or Authority
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Sigma r Date
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E1it 0d x 4t" A. Robb , a Notary Public of the County of \i'4&L t'
State of North Carolina, hereby certify that 3ht.,c 't Y%1(11 appeared
personally before me this day and being duly sworn acknowledged that the abov form was executed by him.
Witness my hand and notarial seal,this I. day of N4 , 2
.`a���_$ .�be A;� Not
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01AR i My ommission expires as
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