NCC240520_FRO Submitted_20240223

- WPM WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
V1�AKE No person may initiate any land-disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
COUNTY sedimentation control plan have been completed and approved by Wake County Department of
;`om il ti,o 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 Sanctuary at Lake Wheeler Lots 7, 26, and 28
2. Location of land-disturbing activity: Jurisdiction Wake County (Wake Co. or Municipality)
Highway/Street Lake Wheeler Latitude 35.7057 Longitude -78.6895
3. Approximate date land-disturbing activity will commence: 2-1-2024
4. Type of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste
areas):2.27
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chris Wagoner E-mail Address [e-mail]
Telephone [phone] Cell# 919-745-7489 Fax#
7. Landowner(s)of Record (attach accompanied page to list additional owners):
Wagoner Homes, Inc 919-745-7489 [e-mail]
Name(s) Telephone Fax or E-mail address
PO Box 58602 1224 Explorer Trl
Current Mailing Address Current Street Address
Raleigh, NC 27658 Wake Forest, NC 27587
City State Zip City State Zip
8. Deed Book No. 019522 Page No. 01682-01685 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):
Wagoner Homes, Inc [e-mail]
Name E-mail Address
PO Box 58602 1224 Explorer Trl
Current Mailing Address Current Street Address '
Raleigh, NC 27658 Wake Forest, NC 27587
City State Zip City State Zip
Telephone [phone] 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,Aggive name and street address of the Registered Agent:
Or 414/ I
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Name of Registered Agent E-mail Address V
/V®$1L 'f3o//c 4 / ®/- e.A.EXIVark 6
Current Mailing Address Current Street Address
jet hz3 L Ne' oltkr Aeley‘ Ail' .9-76
City ,/� State Zip City State Zip
Telephone ?CI` 795_ IVY7 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.
Chris Wagoner Vice President
Type or print na e Title or Authority
a —`�.` /- 3 - am
Signature �� Date
I, Pc-\-E X.AS L. .1 L 0 V-- , a Notary Public of the County of u1/4.DQ�.e_
State of North Carolina, hereby certify that GV1 v t S l.� Dne1r appeared
personally before me this day and being duly sworn acknowledged that the a ve form was executed by him.
Witness my hand and notarial seal, this a� day of 20.44-
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