NCC222207_FRO Submitted_20220615

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land -disturbing activity on one or more acres as covered by 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
NORTH CAR011NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name NC 48 - Griffin
2. Location of land -disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Wyndhorse Lane Latitude 36.07328 Longitude-78.69906
3. Approximate date land -disturbing activity will commence: 3/ 14/2022
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 85
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad Kauffman E-mail Address [e-mail]240
Telephone Cell # 240-495-0511 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Bryan and Thaleisha Griffin 808-343-8721 griffbtgQyahoo.com
Name(s) Telephone Fax or E-mail address
3950 Fairsted Drive
Current Mailing Address Current 9treet Address
Raleigh, NC 27612
City State Zip City State Zip
8. Deed Book No. 018757 Page No. 01773-01774 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):
Bryan and Thaleisha Griffin Land Owner griffbtg @yahoo, corn
Name E-mail Address
3950 Fairsted Drive
Current Mailing Address Current Street Address
Raleigh NC 27612
City State Zip
Telephone [phone]
City State Zip
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:
Name E-mail Address
Current Mailing Address
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
(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
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.
SM (W.W12 1616-4to, & gin_
Type or print name Bryan and Thaieisha Griffin
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Land Owner
Title or Authority
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1, "f !a WI& L. t , a Notary Public of the County of f
State of North Carolina, hereby certify that (llt'XYl QI'ld �}1G�215�?Q Car1ff-rn_ appeared
personally before me this day and being duly sworn ackdo�wledged that the above form was executed by him.
Witness my hand and notarial seal, this _V_day of _1 r r Q,1 m , 20._.&a_ ____
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