20201252 Ver 1_401 Application_20210125

DWR
Division of Water Resources
Pre -Construction Notification (PCN) Form
September 1, 2020 Ver 3.2
Initial Review
Has this project met the requirements for acceptance in to the review process?*
r Yes
r No
Is this project a public transportation project?*
C Yes r No
Change only if needed.
BIMS # Assigned * Version#*
20201252 1
Is a payment required for this project?*
r No payment required
What amout is owed?*
r Fee received
r $240.00
r Fee needed - send electronic notification
r $570.00
Reviewing Office *
Select Project Reviewer*
Central Office - [phone]
Rick Trone:eads\rvtrone
Information for Initial Review
1a. Name of project:
McKenzie Meadows
1a. Who is the Primary Contact?*
Deborah Shirley
1b. Primary Contact Email:*
[e-mail]
Date Submitted
1/25/2021
Nearest Body of Water
Little River
Basin
Neuse
Water Classification
WS-V;NSW
Site Coordinates
Latitude:
35.797098
A. Processing Information
County (or Counties) where the project is located:
Wake
Is this a NCDMS Project
r Yes r No
Longitude:
-78.353602
Is this project a public transportation project?*
r Yes r No
1a. Type(s) of approval sought from the Corps:
W Section 404 Permit (wetlands, streams and waters, Clean Water Act)
r Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
1c. Primary Contact Phone:*
[phone]
L.1
1b. What type(s) of permit(s) do you wish to seek authorization?

W Nationwide Permit (NWP)
r Regional General Permit (RGP)
r Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?
r Yes r No
Nationwide Permit (NWP) Number:
NWP Numbers (for multiple NWPS):
NWP 12 for offsite utility
1d. Type(s) of approval sought from the DWR:
W 401 Water Quality Certification - Regular
r Non-404 Jurisdictional General Permit
r Individual Permit
29 - Residential Developments
le. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
For the record only for Corps Permit:
F- 401 Water Quality Certification - E)press
P Riparian Buffer Authorization
1f. Is this an after -the -fact permit application?*
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
1g. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
r Yes r No
Acceptance Letter Attachment
1h. Is the project located in any of NC's twenty coastal counties?
r Yes r No
1j. Is the project located in a designated trout watershed?
r Yes r No
B. Applicant Information
1d. Who is applying for the permit?
r Owner W Applicant (other than owner)
le. Is there an Agent/Consultant for this project?*
r Yes r No
2. Owner Information
2a. Name(s) on recorded deed:
Cone Avenue LLC, Music Row Investments LLC
2b. Deed book and page no.:
Book: 018192 Page: 01141
2c. Responsible party:
Ann Knott, Aubrey & Sidney Baynes
2d.Address
Street Address
1064 N Lakeside Drive
Address tine 2
city
Smithfield
Postal / Zip Code
27577-8382
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
2a. Name(s) on recorded deed:
Olde Heritage Builders & Realty Inc
State / Rwince / Ifgion
NC
Country
USA
2f. Fax Number:
r Yes r No
r Yes r No

2b. Deed book and page no.:
Book: 006319 Page: 00591
2c. Responsible party:
Chuck Corbett
2d.Address
Street Address
P.O. Box 40
Address Line 2
City
Zebulon
Postal / Zip Code
27597-0040
2e. Telephone Number:
[phone]
2g. Email Address:*
[e-mail]
3. Applicant Information (if different from owner)
3a. Name:
Kirby LaForce
3b. Business Name:
Carolina Land Group, LLC
3c.Address
Street Address
341 Kilmayne Drive, Suite 201
Address Line 2
City
Cary
Fbstal / Zip Code
27511
3d. Telephone Number:
[phone]
3f. Email Address:*
[e-mail]
4. Agent/Consultant (if applicable)
4a. Name:
Deborah Shirley
4b. Business Name:
Soil & Environmental Consultants, PA
4c.Address
Street Address
8412 Falls of Neuse Road, Suite 104
Address Line 2
City
Raleigh
Fbstal / Zip Code
27615
4d. Telephone Number:
[phone]
4f. Email Address:*
[e-mail]
Agent Authorization Letter*
SEC Agent Authorization Form Applicant -McKenzie Meadows.pdf
C. Project Information and Prior Project History
1. Project Information
State / Province / legion
NC
Country
USA
2f. Fax Number:
State / Province / Region
NC
Country
USA
3e. Fax Number:
State / Province / legion
NC
Country
USA
4e. Fax Number:
[phone]
113.03KB

1b. Subdivision name:
(d appropriate)
1c. Nearest municipality/ town:
Wendell
2. Project Identification
2a. Property Identification Number:
1794056758,1794157657,1794161410,
1794066233,1794052762,1794256786
2c. Project Address
Street Address
815 Old Zebulon Road
Address tine 2
aty
Wendell
Fbstal / Zip Code
27591
3. Surface Waters
3a. Name of the nearest body of water to proposed project:*
Little River
3b. Water Resources Classification of nearest receiving water:*
WS-V:NSW
3c. What river basin(s) is your project located in?*
Neuse
3d. Please provide the 12-digit HUC in which the project is located.
030202011503
4. Project Description and History
2b. Property size:
+/-69.57 acres
State / Province / legion
NC
Country
USA
4a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:*
Basting conditions onsite consist primarily of forested and agricultural land. There is one (1) perennial stream feature (SA), two (2) wetland features (W1 & W2), and one (1) non -
jurisdictional pond (Pond 1) located on the property. Perennial Stream'A' bounds the property to the South with adjacent wetland 'W1'. Non -jurisdictional Pond 1 is located just above
the wetland on the southeastern side of the property. 'W2' is located near the center of the property just to the west of the agricultural field. The general land use in the vicinity of the
project consists of residential developments along with forested land.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past?*
r Yes r No r Unknown
4d. Attach an 8 1/2 X 11 excerpt from the most recent version of the USGS topographic map indicating the location of the project site. (for DWR)
USGS.pdf
3.06MB
4e. Attach an 8 1/2 X 11 excerpt from the most recent version of the published County NRCS Soil Survey map depicting the project site. (for DWR)
SS.pdf 1.01 MB
4f. List the total estimated acreage of all existing wetlands on the property:
ApproArnately 4.80 ac
4g. List the total estimated linear feet of all existing streams on the property:
Approximately 1,450 LF
4h. Explain the purpose of the proposed project:*
The purpose of this project is to construct a mixed single-family and multi -family residential development and necessary infrastructure.
41. Describe the overall project in detail, including indirect impacts and the type of equipment to be used:*
The overall project consists of the construction of single-family and multi -family residential development, including but not limited to roads, stormwater devices, utilities, amenity building,
and residential structures. Specifically, there is one (1) road crossing that impacts wetlands and one (1) aerial utility crossing that impacts streams, wetlands, and riparian buffers.
Equipment typically used for construction and earthwork such as backhoes, bulldozers, excavators, graders, pavers etc. will be utilized for this project.
4j. Please upload project drawings for the proposed project.
McKenzie Meadows Impact Map Set 2021-01-22 4th Submittal.pdf 3.13MB
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
r Yes r No r Unknown
Comments:
5b. If the Corps made a jurisdictional determination, what type of determination was made?*

R Preliminary r Approved r Not Verified r Unknown r N/A
Corps AID Number:
SAW-2019-01416
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Steven Ball
Agency/Consultant Company: Soil & Environmental Consultants, PA
Other:
5d. List the dates of the Corp jurisdiction determination or State determination if a determination was made bythe Corps or DWR
USACE: Site visit and field determination made on August 20, 2019 by Samantha Dailey.
NCDWR: Site visit and field determination made on October 31, 2019 by Erin Deck & Zach Thomas (NBRRO #19-270).
We received JD concurrence via email on December 21, 2020 from Samantha Dailey of the USACE.
5d1. Jurisdictional determination upload
Buffer letter without offsite.pdf 1.12MB
Buffer letter including offsite.pdf 531.73KB
SAW-2019-01416 Baynes Tract JD Concurrence.pdf 97.25KB
6. Future Project Plans
6a. Is this a phased project?*
r: Yes r No
7b. If yes, explain.
There are a total of four (4) phases, all proposed impacts are included within this application.
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity?
it is my understanding that there are no intended future phases beyond the property boundaries shown. Therefore, no additional NWP, Regional General Permits, or IP are anticipated.
D. Proposed Impacts Inventory
1. Impacts Summary
la. Where are the impacts associated with your project? (check all that apply):
W Wetlands W Streams -tributaries m Buffers
r Open Waters r Pond Construction
2. Wetland Impacts
2a1 Reason (?)
2b. Impact type * (?)
2c. Type of W.*
2d. W. name *
2e. Forested *
2f. Type of
Jurisdicition*(?)
2g. Impact
area*
Im act A
P
Road Crossing
9
P
Headwater Forest
W2
Yes
Both
0.061
(acres)
Im act A
P
Road Crossing-
9-
T
Headwater Forest
Yes
Both
0.014
Construction Access
�W2
(acres)
Impact B
Aerial Utility Crossing
P
Bottomland Hardwood Forest
W1
Yes
Both
0.137
(Permanent -no
(acres)
Permanent Loss)
Impact B
Aerial Utility Crossing-
Bottomland HaForest
frdwood1
Yes
Both
0.057
Construction Access
JL
(acres)
2g. Total Temporary Wetland Impact
0.071
2g. Total Wetland Impact
0.269
2h. Comments:
3. Stream Impacts
2g. Total Permanent Wetland Impact
0.198
3a. Reason for impact (?) 3b.lmpact type * 3c. Type of impact* 3d. S. name * 3e. Stream Type * 3f. Type of 3g. S. width* 3h. Impact
(?) Jurisdiction* i length*

S1 Impact B-Aerial Utility Temporary Other Stream A Perennial Both 12 51
Crossing -Temporary Average (feet) (linearfeet)
Construction Access
3i. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
0
3i. Total stream and ditch impacts:
51
3j. Comments:
6. Buffer Impacts (for DWR)
6a. Project is in which protect basin(s)?
Check all that apply.
V Neuse
r Catawba
r Goose Creek
C Other
3i. Total temporary stream impacts:
51
r Tar -Pamlico
r Randleman
r Jordan Lake
5b. Impact Type 6c. Per or Temp 6d. Stream name 6e. Buffer mitigation required? 6f. Zone 1 impact 6g. Zone 2 impact
mpact B-Aerial Utility Crossing P Stream A No 3,203 2,342
6h. Total buffer impacts:
Zone 1 Zone 2
Total Temporary impacts: 0.00 0.00
Zone 1
Zone 2
Total Permanent impacts: 3,203.00
2,342.00
Zone 1
Zone 2
Total combined buffer impacts: 3,203.00
2,342.00
6i. Comments:
Supporting Documentation
E. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
S&EC completed a wetland delineation and Neuse River Buffer evaluation for the entire property and Within offsite utility corridor in order to identify
natural resources so that impacts could be avoided & minimized to the maximum eMent practicable. Impact area A is proposed permanent and
temporary wetland impacts for a road crossing. This road crossing serves as a secondary connection between the western and eastern portions of the
development. The crossing has been designed to cross the wetland at the narrowest point of wetland W2 which minimizes wetland impacts. Headwalls
and wingwalls are also being utilized to minimize the overall wetland impacts. Retaining walls cannot have geogrid in the public R/W, so that's why they
are not being utilized more at this crossing to further minimize wetland impacts. Compensatory mitigation is proposed for this permanent loss impact.
Impact area B is proposed permanent (no permanent loss) and temporary wetland impacts, temporary stream impacts, and permanent buffer impacts
for an aerial gravity sanitary sewer crossing. These temporary wetland and stream impacts are necessary for construction activities. The permanent -
no permanent loss impacts are identified because this will be the permanent maintenance corridor, compensatory mitigation is proposed for this
permanent -no permanent loss impact. This utility crossing will be tying into an existing sever outfall so the connection location was set, additionally the
existing ouffall is approximately 3' deep. In order to allowthe sewer gravity flow, the sewer outfall must go above the stream channel resulting in an
aerial crossing. Temporary stream impacts will be brought back to pre -construction stream bed elevations and the stream banks will be stabilized.
Temporary wetland impacts will be brought back to pre -construction contours and the existing adjacent wetland seed source will assist in the
restoration of the wetland vegetation.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
Per the project engineer, silt fencing will be utilized along With slope matting.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
v
2a. Does the project require Compensatory Mitigation for impacts to Waters of the U.S. or Waters of the State?

r Yes r No
2c. If yes, mitigation is required by (check all that apply):
V DWR W Corps
2d. If yes, which mitigation option(s) will be used for this project?
W Mitigation bank r Payment to in -lieu fee r Permittee Responsible
program Mitigation
3. Complete if Using a Mitigation Bank
3a. Name of Mitigation Bank:
EBX-Neuse Sponsored Neu -Con Wetland & Stream Umbrella Mitigation Bank, specifically from the
Hannah Bridge Site
3b. Credits Purchased/Requested (attach receipt and letter)
Type: Quantity:
Riparian wetland 0.26
Attach Receipt and/or letter
Neu -Con SOA - Hannah Bridge - McKenae Meadows.pdf
3c. Comments
Permanent Wetland loss impact = 0.061 acres; 0.061 @ 2:1 mitigation ratio = 0.122 acres
Permanent, No Permanent loss impact = 0.137 acres; 0.137 @ 1:1 mitigation ratio = 0.137 acres
Total mitigation requested = 0.26 acres
139.8KB
6. Buffer mitigation (State Regulated Riparian Buffer Rules) - required by DWR
6a. Will the project result in an impact within a protected riparian buffer that requires buffer mitigation? If yes, you must fill out this entire form - please contact DWR for more
information.
r Yes r No
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1. Diffuse Flow Plan
1a. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
r Yes r No
What type of SCM are you providing?
r Level Spreader
r Vegetated Conveyance (lower SHWT)
r Wetland Swale (higher SMNT)
17 Other SCM that removes minimum 30 % nitrogen
r Proposed project will not create concentrated stormwater flow through the buffer
Diffuse Flow Documentation
961-19 POST DA-C-3.0.pdf 1.11 MB
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
r Yes r No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
r Yes r No
2c. Does this project have a stormwater management plan (SMP) reviewed and approved under a state stormwater program or state -approved local government stormwater
program?
r Yes r No
r N/A - project disturbs < 1 acre
2d. Which of the following stormwater management program(s) apply:
W Local Government r State
Local Government Stormwater Programs
W Phase II W NSW r USMP W Water Supply
Please identify which local government stormwater program you are using.
Wake County
Comments:
G. Supplementary Information

1. Environmental Documentation
1a. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?*
r Yes IT No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15ANCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules (15A NCAC 2B .0200)?*
r Yes IT No
3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality?*
r Yes IT No
3b. If you answered "no," provide a short narrative description.
We have reviewed the "Draft Internal Policy, Cumulative impacts and the 401 Water Quality Certification and Isolated Wetlands Programs' document
prepared by the NC Division of Water Quality on April 10, 2004, version 2.1. The draft states that many private developments are unlikely to cause
cumulative impacts, including projects such as urban in -fill, most residential subdivisions and small commercial developments as well as agricultural
and silvicultural operations. The McKenzie Meadows project is a residential development. Additionally, the project is located within the Wake County
and the Town of Wendell ETJ, therefore the adjacent properties that have potential for development will have the following regulations to protect
downstream waters: 1) the Neuse River Basin Riparian Buffer Protection regulations, these regulations require limited development within the riparian
buffer area, in addition Best Management Practices may be required that control nitrogen if diffuse flow cannot be achieved, 2) the Phase II NPDES
Stormwater Permit Program, this program includes permitting requirements for Municipal Separate Storm Sewer Systems (MS4s) in addition to post -
construction stormwater management requirements, and 3) the Water Supply, Watershed Protection Program which limits development densities as
well as requires protective riparian buffers. We anticipate that the DWR will advise us if any additional information is needed.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?*
r Yes r No r WA
4b. Describe, in detail, the treatment methods and dispositions (non -discharge or discharge) of wastewater generated from the proposed project. If the wastewater will be treated
at a treatment plant, list the capacity available at that plant.
Non -discharge wastewater will be generated and treated at a City of Raleigh WWTP.
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
r Yes r No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?*
r Yes r No
5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?*
r Yes r No r Unknown
5e. Is this a DOT project located within Division's 1-8?
r Yes IT No
5f. Will you cut anytrees in order to conduct the work in waters of the U.S.?
r Yes r No
5g. Does this project involve bridge maintenance or removal?
r Yes IT No
5h. Does this project involve the construction/installation of a wind turbine(s)?'
r Yes r No
51. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
r Yes IT No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
S&EC completed a Threatened & Endangered Species Report, to include a Self -Certification letter through the US Fish &Wildlife Service (USFWS), a
query through the NC Natural Heritage Program database, and an official Species List through the iPac. A formal request was sent to the USFWS on
October 27, 2020. The USFWS has 30 days to respond from the date of the sent request. S&EC received no response from USFWS within the 30
days meaning that they concurred with the determinations made by S&EC that the proposed actions is not likely to adversely affect any federally -listed
endangered or threatened species, their formally designated critical habitat, or species currently proposed for listing under the Endangered Species
Act (ESA). Please see attached S&EC Threatened & Endangered Species report.
Consultation Documentation Upload
S&EC Mckenzie Meadows T&E Report.pdf 8.37MB

6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
r Yes r No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?*
The NOAA Habitat Conservation/Habitat Protection: National Marine Fish Service; Essential Fish Habitat Mapper website was referenced. No Essential
Fish Habitat was identified near the project.
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal governments have designated as having historic or cultural preservation status?*
r Yes r No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?*
The NC State Historic Preservation Office HPOWEB GIS Service interactive map was referenced on September 24, 2020, no historic listings or study
list entries or determined eligible listings were identified within the property boundaries. Additionally, no structures exist within the property boundaries.
7c. Historic or Prehistoric Information Upload
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain?*
r Yes r No
8b. If yes, explain how project meets FEMA requirements:
The project engineers have submitted a letter of map revision to modify the 100-year floodplain. There are no above grade fills proposed within the
FEMA 100-year floodplain.
8c. What source(s) did you use to make the floodplain determination?*
NC Flood Risk Information System Floodplain Mapping Program and confirmation from the project engineer.
Miscellaneous
Comments
Miscellaneous attachments not previously requested.
V
Signature U
W By checking the box and signing below, I certify that:
• I have given true, accurate, and complete information on this form;
• I agree that submission of this PCN form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act');
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
• I intend to electronically sign and submit the PCN form.
Full Name:
Deborah E. Shirley
Signature
Date
1 /25/2021

fires
EBX-Neuse I, LLC Stream and Wetland Banks
Statement of Availability January 25, 2021
U.S. Army Corps of Engineers
Samantha Dailey
Raleigh Regulatory Field Office
3331 Heritage Trade Center, Suite 105
Wake Forest, NC 27587
Re Project: McKenzie Meadows
This document confirms that Kirby LaForce (Applicant) for the McKenzie Meadows (Project) has
expressed an interest to utilize 0.26 Riparian Wetland Mitigation Credits from the EBX-Neuse
sponsored Neu -Con Wetland & Stream Umbrella Mitigation Bank, specifically from the Hannah Bridge
Site in the Neuse HUC 03020201. As the official Bank Sponsor, EBX-Neuse I, LLC, attests to the fact
that mitigation is available for reservation at this time.
These mitigation credits are not considered secured, and consequently are eligible to be used for alternate
purposes by the Bank Sponsor, until payment in full is received from the Applicant resulting in the
issuance of a Mitigation Credit Transfer Certificate by the bank acknowledging that the Applicant has
fully secured credits from the bank and the Banker has accepted full responsibility for the mitigation
obligation requiring the credits/units.
The Banker will issue the Mitigation Credit Transfer Certificate within three (3) days of receipt of the
purchase price. Banker shall provide to Applicant a copy of the Mitigation Credit Transfer Certificate and
a documented copy of the debit of credits from the Bank Official Credit Ledger(s), indicating the permit
number and the resource type secured by the applicant. A copy of the Mitigation Credit Transfer
Certificate, with an updated Official Credit Ledger will also be sent to regulatory agencies showing the
proper documentation.
If any questions need to be answered, please contact me at 919-209-1055.
Best Regards,
Caitlan B. Parker
Resource Environmental Solutions, LLC
701 E. Bay Street, Suite 306
Charleston, SC 29403

8412 Falls of Neuse Road, Sate 104, Raleigh, NC 27615 - Pbone: (919) W-59(0 - FAx,, (919) W-9407
m1do;,cm
AGENT AUTHORIZATION
Project Name/Description: Mckenzie Meadows
Date: 12 - 7, Id
The Department of the Anny
U.S. Army Corps of Engineers,
69 Darlington Avenue
Wilmington, NC 28403
Wilmington District
S&EC Project # 13918 —
Attn: —Samantha Dailey Field Office:. Raleigh Regulatory Field Office
1, the undersigned, authorizes S&EC, as my agent, to act on my behalf and take all actions necessary for
the processing, issuance and acceptance of a permit or certification and any and all associated standard
and special conditions. This notification supersedes any previous correspondence concerning the agent for
this project,
PARCEL INFORMATION:
Parcel Index Number(s) (PIN): 1794056758, 1794052762 1794157657, 1794256786, 1794161410 &
1794066233
Site Address: 815 Old Zebulon Road
City, County, State: Wendell, Wake County, NC
APPLICANT INFORMATION:
Name: rK tV*^ t rh goAams 1>eve.1%*04 W-C,
Mailing Address: 031 14aA9_VVM 044AA Ai- I Q3 C4AN, Nt, 41511
Telephone Number: '704-60t—SOIC
Email: c ou44#At.ca#--
to
Applicant (please print) Date
Applicant SAnaturc
We hereby certify the above information submitted In this application Is true and accurate to
the best of our knowledge.

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Date: Source: 2016 NC
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