NCC232699_FRO Submitted_20230929

WAKE COUNTY FlNANCiAL RESP0NSIBIUTY/OWNERSH(PFORM
SEDI8#ENTATONPOLLUT8ON CONTROL ACT
No person may initiate any land-diStUrbing activity on one or more acres as covered by the Wake
W Coon�y Unified Development Ordinance before this form and an acceptable erosion and
� CO\]N]_,/ sedimentation control plan have been completed and approved by Wake County Department of
Environmental Seminon, VVator Quality Division. (Please typo or print and ifthe question is not
eppUcmb|e. place N/A in the Wjank '
Part A.
1 PnoJnct �am� ) �L ��° 8�~ �
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| 2. Locutiun of land-disturbing activity- Jurisdiction r7`ves+ yWunioipu|ity)
HiAhwm�ste� ��0��/ mJe�� L"t��,����°��} Long �� ^'50)or
�_ �����m ^
3� Approximate date land-disturbing activity will commence: O ^
4. Type of development (rouidenUo|, oommennie|, induotriu|, institutional, etoJ
5, Tntal acreage disturbed or uncovered (including off-site
areas): u�|�eo and borrow/waste^wa�ta
. /m���
G. Person 'to contact ahou|dorookm and aedimor�oontrn issues ahee during kand-distud`inOaotivity
Num L � | 1 . /�\
�7��� _ �-maU Add�s�- K�����y� n-e-rr'com
Telephone-, .�/�_� ���//�7 Cell# Fax
/ Landowne,(x}mfRornnd (attavhanoompaniedpeOeto1|ntoduitiona(ownern):
,
elephone
Current Mailing Address
'Current Street Address
°"x �oara Zip City �� State Zip
S. Deed Book. No. Page No. y3/q / 3 Provide o copy of the most current deed.
parfB'
1 Pe,eon(o} or firm(s) who are finanoiaUy reoponoib|o fu/ the land-disturbing activity (Provide �
comprehenmive |istofeU parties-
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�Uu / / � .
Name �����' / ���~��--
z a_Addre,,
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Current Meiling Address --
Curren!Street Address - -
"
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State Zip City State Zip
Te|ephnne /J/'0' g 34 FaxNunnbe[_ __ ~-__ `

2. (u) 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
mal.',er na|adnQ to the Wake County Erosion and Sedimentation - nUn| ordinance and/or Land
Disturbance Permit:
Name E-mail Address
Current Mailing Address Current Street Address
city State Zip Cih/ State Zip -
Telephone FaxNuMher
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed namo, 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 ofRegistered Agent E-mail Address
Current Mailing Address -- — Cur-rent 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 belie'and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individualor his aftonoey-in-fact, or /f not an individua|, by'an officer, director, padner, or registered agent With
the authority to oneouba instruments for the Financially Responsible Pe`on\ i agree to provide
corrected infunnmUunshould there be any change in the information provided 'erein.
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