NCC212404_ESC Approval Submitted (2)_20210512

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
W 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
NORM CAIk0I DNA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A.
Project Name Georgia's Landing__- Force Main
2. Location of land -disturbing activity: Jurisdiction. Wake (Wake Co. or Municipality)
Simpkins Rd
Highway/Street Fayetteville Rd Latitude 35.796080 Longitude-78.267770
4
E.
Approximate date land -disturbing activity will commence: _ April 2021
Type of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage
areas): 7.2
disturbed or uncovered (including off -site utilities and borrow/waste
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Adam Speiran E-mail Address [e-mail]
Telephone [phone] Cell # NA Fax # _ N/A
Landowner(s) of Record (attach accompanied page to list additional owners):
Clayton Properties Group,INC
Name(s)
919-303-8525
Telephone
[e-mail]
Fax or E-mail address
2521 Scheiffelin Rd Ste 116 2521 Scheiffelin Rd Ste 116
Current Mailing Address Current Street Address
Apex NC 27502 Apex NC 27502
City State Zip City State Zip
018342 01568
Deed Book No. 018342 Page No. oissa 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):
Clayton Properties Group, INC [e-mail]
Name E-mail Address
2521 Scheiffelin Rd Ste 116
Current Mailing Address
Apex NC 27502
City State Zip
Telephone [phone]
2521 Scheiffelin Rd Ste 116
Current Street Address
Apex _ NC 27502 _
City State Zip
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:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
Moore & Alphin
Name of Registered Agent
Current Mailing Address
Raleigh, NC 27612
City State
Telephone [phone]
[e-mail]
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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 attomey-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.
Adam S eiran
Type or print name
Signature
Assistant Secretary
Title or Authority
3-�',2l
Date
I, ---,a Notary Public of the County of ► &k-e ,..
State of North Carolina, hereby certify that ad& /r1 J 1� appeared
personally before me this day and being duly swom acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this 6Aay of AafrA , 20 '-1-1
EIMBEROY DARK Notary
Notarygj�olic. North CarolinaWake County My commission expires
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