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HomeMy WebLinkAboutNCC232870_FRO Submitted_20230922 WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land-disturbing activity on one or more acres as covered by the Wake V VIE Cfied em Ordinance before COUNTY sedimentation controlDev planlop ent have been completed andthis approvedform byand an Wake Countyacceptable Departerosionmentand of 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 Wexford Reserve Lot 59 2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality) Highway/Street Wexford Waters Lane Latitude 35-991313 Longitude -78.547336 3. Approximate date land-disturbing activity will commence: 10/2023 4. Type of development(residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 0.29 6. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Chris Elliott E-mail Address Chris@wilksbuilders.com Telephone (919)630-1995 Cell# (919)630-1995 Fax# 7. Landowner(s)of Record (attach accompanied page to list additional owners): Wilks Builders Inc. (919)868-4425 wilksbuildersinc@gmail.com Name(s) Telephone Fax or E-mail address 4213 Worley Dr. 4213 Worley Dr. Current Mailing Address Current Street Address Raleigh NC 27613 Raleigh NC 27613 City State Zip City State Zip 8. Deed Book No. 019246 Page No. 02092 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): Wilks Builders Inc. wilksbuildersinc@gmail.com Name E-mail Address 4213 Worley Dr. 4213 Worley Dr. Current Mailing Address Current Street Address Raleigh NC 27613 Raleigh NC 27613 City State Zip City State Zip Telephone (919)868-4425 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 provided herein. Neil Wilks Owner Type or print na Title or Authority /,:�j �--� 6/29/23 Signatu Date I, littnAt liftwo4 131.4fit , a Notary Public of the County of WitIl.t State of North Carolina, hereby certify that ,;LY�. WitILS 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 day of + - , 20 2,5 Notary w .,. 7,} st My Commission expires --3QMy COCIritt,i 't-S