NCC231983_FRO Submitted_20230628

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKENo person may initiate any land-disturbing activity on one or more acres as covered by the Wake
WAK 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
n, ,1 H �� 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 NameBerklee Estates Well #4 Lot
2. Location of land-disturbing activity: Jurisdiction Wake Co (Wake Co. or Municipality)
Highway/Street Dolce Drive Latitude 36.0083 Longitude-78.5205
3. Approximate date land-disturbing activity will commence: March 2023
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):0.34 acres
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Johnny Averett E-mail [e-mail]
Telephone [phone] Cell# Same Fax# N/A
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Crosswind Development Inc n/a
Name(s) Telephone Fax or E-mail address
2550 Capitol Dr Suite 105 Same
Current Mailing Address Current Street Address
Creedmoor NC 27522 Same
City State Zip City State Zip
8. Deed Book No.016230 Page No.02366 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):
Crosswind Development Inc [e-mail]
Name E-mail Address
2550 Capitol Dr Suite 105 Same
Current Mailing Address Current Street Address
Creedmoor NC 27522 Same
City State Zip City State Zip
Telephone [phone] Fax Number N/A

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:
Christopher Lewis [e-mail]
Name E-mail Address
PO Box 91727 8951 Harvest Oaks Dr, Ste 205
Current Mailing Address Current Street Address
Raleigh NC 27675 Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number N/A
(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:
William H. Wynn [e-mail]
Name of Registered Agent E-mail Address
2550 Capitol Dr Suite 105 Same
Current Mailing Address Current Street Address
Creedmoor NC 27522 Same
City State Zip City State Zip
Telephone [phone] Fax Number N/A
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.
William H. Wynn President
Type or print name Title or Authority
�ti' ..r.. W 3/a"/a3
Signature Date
Pnt !"� , a Notary Public of the County of (& vt ti•vJG(2.
State of North Carolina, hereby certify that (j);i).'cirn H W appeared
personally before me this day and being duly sworn acknowledged that the'above form was executed by him.
Witness 7,,,hionn id notarial seal, this - 1 day of I • • , 20 D'3
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