NCC223326_FRO Submitted_20220922

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
�+■�1II 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
Environmental Services, Water Quality Division. (Please type or print and, if the question is not
i applicable, place N/A in the blank.)
Part A.
1. Project Name Sweetwater Subdivision - Phase IV Construction Documents
2. Location of land -disturbing activity: Jurisdiction Wake Co (Wake Co. or Municipality)
Highway/Street auburn knightdale rd Latitude Longitude
3. Approximate date land -disturbing activity will commence: spring/summer 2021
4. Type of development (residential, commercial, industrial, institutional, etc.): residential - subdivision
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 5.0 ac
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jesse Satterwhite E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Sweetwater Wake, LLC 9�9-266-0033 [e-mail]
Name(s) Telephone Fax or E-mail address
5933 Farmwell Rd 5933 Farmwell Rd
Current Mailing Address
Raleigh NC 27610
City State
8. Deed Book No. 018019
Current Street Address
Raleigh NC 27610
Zip City State Zip
Page No. 01479 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):
Sweetwater Wake, LLC [e-mail]
Name
5933 Farmwell Rd
Current Mailing Address
E-mail Address
5933 Farmwell Rd
Current Street Address
Raleigh NC 27610 Raleigh NC 27610
City State Zip City State
Telephone 9�9-266-0033 Fax Number
Zip

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, lgive name and street address of the Registered Agent:
se `Jw7��Wh,�c ��" -5 i (-WhJ &CanJ"Agn 1r'10 C��'mou� �Can1
Name of Registered Agent E-mail Address
59-5-5 Fwmwezz Qa��
Current Mailing Address
IIRALE►GA (VL 2-7el(J
City State Zip
Telephone 919 - 2(a6 - oo3-5
Current Street Address
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.
Type or print name -- Title or Authority
- 3 G - Zo z
Signature Date
I, unr I a Notary Public of the County of
State of North Carolina, hereby certify that c ' , �[ R t �i' �� �� 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 XC day of 1 l jrCj►\ , 20 D- �.
-{ RA/
FT '^ l • i.,, �Lj rrro
-` Notary
Seal
_�= My commission expires