NCC216635_FRO Submitted_20211130

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 Environment and Natural Resources. (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.
1. Project Name Wiggins Village Phase II
2. Location of land -disturbing activity: County Franklin City or Township Louisburg
Highway/Street Hicks Road (SR 1125) Latitude 36,039872 N Longilude 78.456414 W
3. Approximate date land -disturbing activity will commence: May 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
9.38 ac previously
5. Total acreage disturbed or uncovered including off -site borrow and waste areas): 6.18 ac
r-455 Paid
6. Amount of fee enclosed: $195 Previously I . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael A. Moss E-mail Address mike @cmppls.com
Telephone [phone] Cell # n/a Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wiggins Towns, LLC n/a n/a
Name Telephone Fax Number
PO BOX 610 n/a
Current Mailing Address Current Street Address
Youngsville NC 27596 n/a n/a n/a
City State Zip City State Zip
10. Deed Book No. 2244 Page No. 1956 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):
Wiggins Towns, LLC mike @cmppls.com
Name E-mail Address
PO BOX 610 n/a
Current Mailing Address
Youngsville NC 27596
City State
Telet�iinr�e 919-556-4700
Current Street Address
n/a n/a n/a
Zip City State
Fax Number n/a
Zip

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
Current Mailing Address
City State
Telepho
E-mail Address
Current Street Address
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:
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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.
/Y1/e0a A lwa5S
Type or print name
Signature
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Title or Authority
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Date
I, hU en , a Notary Public of the County of Wake -
State of North Carolina, hereby certify that _ fM, ch4el 'k . M _'46 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 �7�'" day of , 20 it
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My commission expires .9
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