NCC232047_FRO Submitted_20230705

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
Countysedimentati Unifiedncontrol DevelopmentOrdinance bfe aao
COUNTY on haveOr beeninan completedeor and this approvedform bynd an Wake Countyacceptble Department ofand
NORTH CAROLINA 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 The Grove at Gin Branch
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Turnipseed Road Latitude 35.7373 Longitude-78.39233
3. Approximate date land-disturbing activity will commence: April 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): 8.00 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name George Young E-mail Address George.younqamattamycorp.com
Telephone [phone] Cell#919.625.9546 Fax# None
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Mattamy Homes,LLC 919.625.9546 [e-mail]
Name(s) Telephone Fax or E-mail address
11000 Regency Parkway, Suite 11 Same
Current Mailing Address Current Street Address
Cary NC 27518 Same Same Same
City State Zip City State Zip
8. Deed Book No. 019190 Page No. 00567 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):
Mattamy Homes,LLC george.voungt mattamycoro.com
Name E-mail Address
11000 Regency Parkway,Suite 110 11000 Regency Parkway,Suite 110
Current Mailing Address Current Street Address
Cary NC 27518 Cary NC 27518
City State Zip City State Zip
Telephone [phone] Fax Number None

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 Current Street Address
City State Zip City State Zip
Telephone 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, give name and street address of the Registered Agent:
George Young George.vounq a( mattamvcorp.com
Name E-mail Address
11000 Regency Parkway,Suite 110 11000 Regency Parkway,Suite 110
Current Mailing Address Current Street Address
Cary NC 27518 Cary NC 27518
City State Zip City State Zip
Telephone [phone] Fax Number None
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.
George Young Vice President of Land
Type or print na Title or Authority
2, -t -2.-)Signatur5 Date
I, A 4;4 .-), c=<— , a Notary Public of the County of L%Al'
State of North Carolina, hereby certify that G z' eie y/�'L'='4:" appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness my hand and notarial seal, this 6 day of /e6F'i2-vr3 , 20..,
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