NCC243595_FRO Submitted_20241120

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
NORTH cnaOi.NA 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 Lot 25 Grand Highland Estates
2. Location of land-disturbing activity: Jurisdiction Wake Co (Wake Co. or Municipality)
Highway/Street Legacy Ridge Ln Latitude 36.029605 Longitude -78.594720
3. Approximate date land-disturbing activity will commence: 9/1/24
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas): 0.91
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matthew Kerul E-mail Address [e-mail]
Telephone [phone] Cell # 770-286-1013 Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Bohart, Philip Gregory Co-Trustee 858-204-0606
Bohart, Kimherly Ann Co-Trustee [e-mail]
Name(s) Telephone Fax or E-mail address
1724 Legacy Ridge Ln 1724 Legacy Ridge Ln
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
City State Zip City State Zip
8. Deed Book No. 019630 Page No. 02068 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):
Bohart, Philip Gregory Co-Trustee [e-mail]
Bohart, Kimberly Ann Co-Trustee
Name E-mail Address
1724 Legacy Ridge Ln 1724 Legacy Ridge Ln
Current Mailing Address Current Street Address
Wake Forest NC 27587 Wake Forest NC 27587
City State Zip City State Zip
Telephone [phone] N/A
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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
N/A
Telephone N/A 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 thee any change in the information provided herein.
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Signature rie-)44,.."4,0 , Date 7 -L L./
I, L KA 5 , a Notary Public of the County of SiJiJ ttLVCO _
State of •
N O&e , hereby certify that �� &Rlfi01�1 �30�IAR� Mg6iuM • appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
14
Witness my hand and notarial seal, this_ day of -11 , 20 n
Notary
Seal -SAN- )5, aaq
My commission expires
45�•''rye L.MORALES
Notary Public•California z
I .T San Diego County
� Commission#2434329
••* My Comm.Expires Jan 15,2027