NCC223887_FRO Submitted_20221121

NOQ7H CAROLiNA
Financial Responsibility -ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson Sedimentation and Erosion Control
Ordinance before completing and filing this form with the City of Wilson Erosion Control Division. (*Indicate N/A if a question is not
applicable)
Field Name
Description
Comments
PROJECT Tracking
number
Complete
Application/NOI
Application Received date
SIC Code (Primary)
N/A (CHARTER SCHOOL)
Commercial (30001) = 1542, Highway (30005) = 1611, Industrial (30002)
= 1541, Residential, Single Family Houses (SFE) = 1521, Residential,
other than SF (30000) = 1522, others = blank
Project or Site name
WILSON PREPARATORY ACADEMY -FOOTBALL
PRACTICE FIELD
Site Street Address
TILGHMAN ROAD
Site City
Wilson
Site County
Wilson
Site State
NC
Site Zip Code
27896
Site/Facility Type of
Ownership
POF
Non -Government = POF (default}
Government -County = CNG
Government - Federal = FDF
Government - Municipal = MWD
Organization Government - State = STF
Approximate Activity
Start Date
OCTOBER 14, 2022
Total Acres of
Distrubance
3.30 ACRES
FRO - First Name
DARYL
**MUST be Financially Responsible Owner Person**
FRO - Last Name
WOODARD
**MUST be Financially Responsible Owner Person**
FRO - Organization
Formal Name
WILSON PREPARATORY ACADEMY FOUNDATION,
LLC
**MUST belong to Financially Responsible Owner**
FRO - eMail Address
[e-mail]
**MUST belong to Financially Responsible Owner**
FRO - Mailing Street
Address
P.Q. BOX 233
**MU5T belong to Financially Responsible Owner**
FRO - Mailing
Supplemental Location
Text
2755 TILGHMAN ROAD
"MUST belong to Financially Responsible Owner**
FRO - Mailing City
Wilson
**MUST belong to Financially Responsible Owner**
FRO - Mailing State
NC
**MUST belong to Financially Responsible Owner**
FRO - Mailing Zip Code
27894-0233
**MUST belong to Financially Responsible Owner**
Latitude: Decimal
Degrees
35.768
Longitude: Decimal
Degrees
-77.920

MM
-0
(#) ACRES TO BE DISTURBED 3_3 X $150.00 /ACRE= $495.00
Person(s) or Firm(s) financially responsible for this land disturbing activity: (If out of state, a registered agent in North Carolina
must be used.)
In case of a violation please list the preferred contact (either the Financially Responsible Person or Registered Agent on the line
below:
or RONNIE L. SUTTON, PE
Financially Responsible Person
Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by me while under oath. (This
form must be signed by the Financially Responsible Person if an individual or by an officer, director, partner, and attorney -in -fact,
or other person with authority to execute instruments for the financially responsible person if not an individual.)
07-27-20
Dote
HEAD OF 5! OOL _FOUNDER
TitleorRuth v 15`'"v A
signotfrre
Daryl Woodard
Type or Print Name
HEAD OF SCHOOL & FOUNDER 10-14-2022
Title Date
�dlx- { �[
n +h a Notary Public of the County of !V�'S� ,State of North Carolina
hereby certifies �I
vA. 1 V YQDilovC ck narcnnally nnnaararl hpfnro mp thk day and under nath arknnwledpad that the
above form was executed by him.
Witness my hand and notary seal, this I LAW day of 0&4"r
(Notary Public)
t`�}j1ti44i1i9lYYerf`�
My commission expires r� ""'