NCC215925_FRO Submitted_20211026

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
WAKECounty 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
NiIRj„ L AR01INA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
applicable, place NIA in the blank.)
Part A.
1. Project Name Raynor Meadows
2. Location of land -disturbing activity: Jurisdiction Garner (Wake Co. or Municipality)
Highway/Street US 70 Hwy Latitude 35-716692 N Longitude 78-630769 W
3. Approximate date land -disturbing activity will commence: Dec 2020
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential (Apartments)
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 16.60
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bart J. McClain, PE E-mail Address [e-mail]
Telephone [phone] Cell # 919-630-4466 Fax # [phone]
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Bobby Carlyle Raynor 919-828-8800 [e-mail]
Name(s) Telephone Fax or E-mail address
PO Box 365
Current Mailing Address Current Street Address
Garner NC 27529
City State Zip City State Zip
S. Deed Book No. 2128 & 2831 Page No. 643 & 689 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):
W & M Partners, LLC [e-mail]
Name E-mail Address
22019 Fairview Road, Suite 200 same
Current Mailing Address Current Street Address
Raleigh NC 27608 same
City State Zip City
Telephone [phone] Fax Number
State Zip

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:
W e641AAS a-•- *-\) d W 111 W W V t t o C4 r\
Name of Registered Agent E-mail Address
o [� w d5o p CS Cam- e u Wa9d 5a
Current Mailing Address Current Street Address
Llr± Z V - 0 C 2- 742
City VState Zip City State Zip
Telephone 2 1 '1 r 4 " —,)T0 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.
Type or print dame
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Signature
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Title or A thori
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Date
I, 11"_IV a Notary Public of the County of Ll/�_
State of North Carolina, hereby certify that L4___i S ► L.,j IZi i..tl,., l appeared
personally before me this day and being duly sworn acknowl dge� ed that tie above form was executed by him.
Witness my hand and notarial seal, this day of &A, �
Seal V---
y commission expires 2.7