NCC232497_FRO Submitted_20230818

1:Wil WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
nifi Development bbo
COUNTY sedimentationCountyU ed control planevelopmen haveOrdinance been completedefore and this approved
form byand an Wake Countyaccepta le Department
er sion ofand
N(1 RI t1 CAI((111NA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place N/A in the blank.)
Part A. f
1. Project Name (1)0{ a I-1 r-co L.-►1� l�t id L)
(J I/
2. Location of land-disturbing activity: Jurisdiction IA)O & (Wake Co. or Municipality)
Highway/Street 1(-0I ?oi& Latitude 'J 5. v(L Longitude- 7 g - 7 3 7 —7 -1
3. Approximate date land-disturbing activity will commence: ✓Q 3 i a FrIt4, I
4. Type of development(residential, commercial, industrial, institutional, etc.): KO- S )0Q4 t{ 4- I
5. Total acreage disitkirbed or uncovered (including off-site utilities and borrow/waste
areas): O • ,55$
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name �Q ( , l Y QrP4-Z.S E-mail Address 4 '1'I1 Q14cOid V QeShOrbe i
Telephone 9' i C o� Sy -y- Cell# 119 -S9 9-6 Nax#
7. Landowner(s)of Record (att ch accompanied page to list additional owners):
rh, �,��s a n 0) 1 R. 4 - g f. a(9d4 h ,;
Name(s) V _ Telephone Fax or E-mail address
Y- 1 Si y T-of ,1 S( ,) �; 9 / c; y ( 6(- r—c' ot(, _c.°3
Current Mailing Address / Current Street Address
L_LV--- IV C� 9 1 4I ;c� NC— 9 -76 IS
City State Zip City ) State Zip
8. Deed Book No. Page No. 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 resp�onsible parties on an attached sheet. Include requested information):
1-11c2 ✓-ens (' ►M Q /11 A- -P-P.)- cs Q d7itskb(110s, (v
Name 1 E-mail Address
cM. "/ Silc tLs l a SOD 9 I S► y -.)( LS .S�
Current Mailing Address Current Street Address
4-6:‘ 14 G P7 c I/ A/c- a- 76 / s
City State Zip City State Zip
Telephone CI 1 4 - ' LL' �`/ 7 Fax Number

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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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,ptQvided herein.
�( r 1 �-n c'ion -Y>{ SichI
Type or prints name Title or Authority
is'/2-3
Sig ure Date
1, 1 h erLYZ It - Ike 1- , a Notary Public of the ounly of lAja.A—�
State of North Carolina, hereby certify that )-Q irrt4 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 S lay of h , 20
ary
THE ESA REFFTZS a
Notary Public My commission expires
Wake County,North Carolina
My Commission Expires
March 6,2024