NCC232786_FRO Submitted_20230922

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Meadowbrook Park Improvements
2. Location of land-disturbing activity: County Wake City or Township Garner
Highway/Street Country Club Dr Latitude(decimal degrees) 35.66372 Longltude(decimal degrees) -78.56921
3. Approximate date land-disturbing activity will commence: 8/28/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.6
6. Amount of fee enclosed $2450 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre(rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Rodney Dickerson E-mail Address [e-mail]
Phone: Office# 919 773 4407 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Garner 919 773 4425
Name Phone: Office# Mobile#
900 7th Ave 900 7th Ave
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
10. Deed Book No.0 16478 Page No.00993 Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Town of Garner [e-mail]
Company Name E-mail Address
900 7th Ave 900 7th Ave
Current Mailing Address Current Street Address
Garner NC 27529 Garner NC 27529
City State Zip City State Zip
Phone: Office# 919 773 4425 Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
TranSystems [e-mail]
Engineering firm or other consultant E-mail Address
Tyler Overby 252-213-0424
Individual contact person (type or print) Phone: Office# Mobile#
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Rodney Dickerson Town Manager
Type or print name Title or Authority
7f 11 ( 23
Signature Date
I, .5l e Lc L-a, bOr'1 , a Notary Public of the County of J offins an
State of North Carolina, hereby certify that p oGkv'P5J t t ciectrSo/) appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this l( tk day of Lj , 20 -3
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#

BK016478PG00993 WAKE COUNTY, NC
LAURA M RIDDICK
REGISTER OF DEEDS
PRESENTED & RECORDED ON
08-01-2016 AT 14:53:09
STATE OF NC REAL ESTATE
EXCISE TAX: $5,800.00
BOOK: 016478 PAGE: 00993-00995
Excise Tax: $5,800.00 Recording Time,Book and Page
Tax Lot No. Parcel Identifier No. 0046557
Mail after recording to: Grantee
This instrument was prepared by: David T. Pryzwansky,The Pryzwansky Law Firm, P.A.
Brief description for the Index: 8025 Country Club Drive, Garner
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made.this 29th day of July,2016,by and between
GRANTOR GRANTEE
Saint Augustine's University, Town of Garner
a North Carolina nonprofit corporation,
successor by name change to Saint
Augustine's College
1315 Oakwood Avenue 914 7th Avenue
Raleigh,North Carolina 27610 Garner,North Carolina 27659
The designation Grantor and Grantee as used herein shall include said parties,their heirs,successors,
and assigns,and shall include singular,plural,masculine,feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of
which is hereby acknowledged,has and by these presents does grant,bargain, sell and convey unto
the Grantee in fee simple, all that certain lot or parcel of land situated in Garner, Wake County,
North Carolina and more particularly described as follows:
Submitted electronically by "The Pryzwansky Law Firm"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the wake County Register of Deeds.

BK016478PG00994
See Exhibit A attached hereto.
The Property conveyed herein does not include the primary residence of Grantor.
The Property was acquired by Grantor by deed recorded in Book 12627,page 1537, Wake County
Registry.
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances
thereto belonging to the Grantee in fee simple.
And the Grantor covenants with the Grantee,that Grantor is seized of the premises in fee simple.,has
the right to convey the same in fee simple, that title is marketable and free and clear of all
encumbrances, and that Grantor will warrant and defend the title against the lawful claims of all
persons whomsoever except for the exceptions hereinafter stated.
Title to the property hereinabove described is subject to the following exceptions:
This property is conveyed subject to restrictions and easements of record affecting said
property and to 2016 ad valorem taxes and taxes for subsequent years,if any.
IN WITNESS WHEREOF,the Grantor has hereto set its hand and seal the day and year first
above written.
Saint Augustine's University,
(corporate seal) a No olina nonprofit corporation
By.
verett B. Ward,President
STATE OF NORTH CAROLINA :
COUNTY OF WAKE
I,a Notary Public,certify that Everett B.Ward,President of Saint Augustine's University,a
North Carolina nonprofit corporation personally came before me this day and being duly authorized
acknowledged the execution of the foregoing instrument on behalf of the corporation.
Witness my hand and official seal,this the 296 day of J 016.
Notary Public
My Commission expires: DAVID T.PRYZWANSKY
AFFIX SEAL NOTARY PUBLIC
WAKE COUNTY,NC
My Commission Expires 5-12-2017
2

BK016478PG00995
/
EXHIBIT A
• LAND
All that tract or parcel of land lying and being in St, Mary's Township,Wake County, North.Carolina, and bounded as
follows:
•
BEGINNING at a stake in the corner of the Raleigh & Wilmington Road corner of Lot No, 5, and runs South 20° 30'
West 524 feet to a'stake in the line of Lot No. 4; thence South 3° West 1570 feet to a stake, corner of Lot No. 2;
thence North 69°30'West 1015 feet to an iron stake,corner of Lot No, 1;thence South 3°10' East 1550 feet, crossing
a branch, to a stake in the run of a branch; thence down said branch South 89° 15' East 320 feet; thence down the
run of said'branch South 59°45' East 246 feet to a stake at the bridge; thence South 54° East 370 feet to a stake;
thence South 53° 30' East 305 feet to a stake; thence South 65° 30' East 621 feet to a stake; thence South 83° 15'
East 320 feet to a stake; thence South 54° East 274 feet to a poplar on the branch;thence North 8°'15' East 1245
feet to a stake in the run of a branch with sweet gum pointers; thence up the said branch North 21°West 600 feet to
a stake; thence North 9° 15'West 122 feet to a stake; thence North 26° 15' West 650 feet to a stake; thence North
12°30'West 440 feet to a stake;thence North 28°15'West 140 feet to a small poplar; thence North 18° 5'East 1100
feet to a stake in the road; corner of Lot No. 8; thence North 77° 35' West 930 feet to the BEGINNING, containing
136.50 acres, more or less, and being Tract 18 according to map recorded in Book of Maps A, Page SO, office of the
•
Clerk of Superior Co of Wake County, N.C. and being Lot No. 29 in the division of the J.A. Vinson estate, allotted to
Pauline V. Smith, and conveyed to D.C. Brooks and wife, by Pauline V, Smith and husband by Deed recorded in
•
Book 752, Page 345,Wake County Registry,and being the same property conveyed to Meadowbrook Country Club,
Inc. by deed dated April 27, 1960, recorded May 3, 1960, in Book 1406, Page 224, Wake County Registry,
SAVE AND EXCEPT FROM THE ABOVE TRACT THE FOLLOWING: •
.Lots I through 22 as shown on map entitled, "Meadowbrook Park Subdivision,Wake County, North Carolina," dated
January I0, 1973, by Sam Powell, RLS and recorded in Book of Maps 1972,Volume 4, Page 481, Registry of Wake,
NC.
Being same property acquired by Saint Augustine's University'(f/k/a Saint Augustine's College) in deed from DCF
Meadowbrook LLC to Saint Augustine's College, dated June 27,2007, and recorded in the Wake County, NC Public
Registry at Book 012627, Page 01537.Wake County, NC Tax Parcel ID 0046557 and PIN 1629850981.