NCC221895_FRO Submitted_20220518

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
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 1-7
2. Location of land -disturbing activity: Jurisdiction — 5� (Wake Co. or Municipality)
Highway/Street , Latitude Longitude -76; : 1904—
3. Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): &L"
5. Total acrea a disturbed or uncovered (including off -site utilities and borrow/waste
areas): ,. 5-
6. Person to
contact should
erosion and sediment control issues arise during land-disturbing/activity:
Named !✓''� E-mail Address
Telephone �'IZ 690 OSq.�2— Cell #
Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Name(s) Telephone Fax or E-mail address
Current Mailing Address
City State Zip
Current Street Address
City
State
53
Deed Book No. Page No.Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Y �J /O, , / /,> �� G G' 1 A CIO el&:� ' %//G :
Name E-mail Address
Current Mailing Address jj
city State Zip
Telephone 711 egg
Current Street Address
City
Fax Number
State
Zip

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