NCC232090_FRO Submitted_20230712

WILSON
NORTH 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 Received date
Application/NOI
Commercial(30001)=1542,Highway(30005)=1611,Industrial(30002)
=1541,Residential,Single Family Houses(SFE)=1521,Residential,
SIC Code(Primary) 30001 other than SFE(30000)=1522,others=blank
Project or Site name Woodridge West III—Phase I&2
Site Street Address Off Western End of Chelsea Drive
Site City Wilson
Site County Wilson
Site State NC
Site Zip Code 27893
Non-Government=POF(default)
Government-County =CNG
Government-Federal=FDF
Site/Facility Type of Government-Municipal=MWD
Ownership POF Organization Government-State=STF
Approximate Activity
Start Date May 1,2023
Total Acres of
Disturbance 21.1 ACRES
FRO-First Name David **MUST be Financially Responsible Owner Person**
FRO-Last Name Evans,Jr. **MUST be Financially Responsible Owner Person**
FRO- Organization
Formal Name Woodridge West,LLC **MUST belong to Financially Responsible Owner**
FRO-eMail Address David Evans,Jr.<[e-mail]> **MUST belong to Financially Responsible Owner**
FRO-Mailing Street
Address 701 W 14th Street **MUST belong to Financially Responsible Owner**
FRO-Mailing
Supplemental Location
Text **MUST belong to Financially Responsible Owner**
FRO-Mailing City Greenville **MUST belong to Financially Responsible Owner**
FRO-Mailing State NC **MUST belong to Financially Responsible Owner**
FRO-Mailing Zip Code 27836 **MUST belong to Financially Responsible Owner**
Latitude:Decimal
Degrees 35.7588
Longitude:Decimal
Degrees
-77.9659

WILSON
NORTH CAROLINA
PROJECT NAME:Wilson County Alcoholic Beverage Control Board
The above information is true and correct to the best of my knowledge and the land disturbing activity
will conform to applicable ordinances. I further agree to indemnify and save harmless the City of
Wilson from any and all liability damages or losses resulting directly or indirectly from the land
dis urbng activities described here on. I acknowledge that violations of erosion control regulations will
re ult of p to$5,000 per d .
1,4
Signature
David Evans,Jr.
Type or Print Name
252-752-2106 3-28-23
Phone 1! Date
2