NCC215916_FRO Submitted_20211028

4KM. roNn of ENGINEERING DEPARTMENT
Holly 128 South Main Street - PO Box 8 Holly Springs, NC 27540
Springs [phone] • FAX [phone]
n OR7l1 ' A R 0 L I N A
Application for Construction Drawing Plan Approval, Erosion & Sedimentation Control Plan Approval. NPDES Stormwater
Review, Land Disturbance Permit Issuance, and Statement of Ownership and Financial Responsibility.
(Check All "That Apply)
❑ Construction Drawing Plan Review ■❑ Erosion & Sedimentation ❑ NPDES Stormwater Review
Control Plan Review
1. Project Name, Project ID, and Phase: FDB - Project Galaxy Phase:
2. Description of Construction/Land Disturbance:
Early Grading
3. Landowner(s) of Record: (Use additional pages if necessary and attach to application)
Fujifilm Diosynth Biotechnologies USA, Inc.
Name Name
101 J Morris Commons Lane
Address
Morrisville, NC, 27560
City, State, Zip
919.583.2686 NIA
Telephone
919.583.2686
Mobile Phone
Fax
Thomas schmalzbauer@[upfilm com
Email Address
Address
City, State, Zip
Telephone Fax
Mobile Phone Email Address
4. Future Landowner(s), If Applicable: (Use additional pages if necessary and attach to application)
Name Name
Address Address
City, State, Zip
Telephone
Fax
Telephone
City, State, Zip
Fax
Mobile Phone Email Address Mobile Phone Email Address
5. List Book & Page where Deed or Instrument is Filed in Wake County:
Location Description: 11751 Holly Springs New Hill Road
Parcel Identification Number (PIN): 0639721435
Book: DB 018600 Page: 01837
Tax Map, Block, and Lot Number: 0639-04
Book:
6. Person(s) or Firms) Financially Responsible for Land -Disturbing Activity
Fujifilm Diosynth Biotechnologies USA, Inc.
Name
101 J Morris Commons Lane
Address
Morrisville, NC, 27560
City, State, Zip
919.583.2686 NIA
Telephone
919.583.2686
Mobile Phone
9001
5l2114
Fax
[e-mail]
Email Address
Telephone
Mobile Phone
Page:
Name
Address
City, State, Zip
Fax
Email Address

Application for Construction Drawing Plan Approval, Erosion & Sedimentation Control Plan Approval, NPDES
Stormwater Review, Land Disturbance Permit Issuance, and Statement of Ownership and Financial Responsibility
7. Registered Agent, if any, for Person(s) or Firm(s) Financially Responsible:
(NOTE: A North Carolina agent is required if the applicant is not a resident of North Carolina.)
Corporation Service Company
Name Telephone
2626 Glenwood Ave, Suite 550
Address
Raleigh, NC, 27608
City, State, Zip
8. Plans Prepared By:
Jacobs I Jamie E. Gollings
Name of Firm/Person
111 Corning Road, Suite 200
Address
Cary, NC, 27518
City, State, Zip
9. Site/Project Information:
Total Size of Tract:
152.62
Length of Sidewalk:
0
Length of Water Line:
0
Length of Greenway:
0
# Stormwater BMPs <
5 acres:
Latitude: 35.6553
FEMA/FIRM Map #: 3720062800J
acres
linear feet
linear feet
Mobile Phone
Fax
Email Address
919.859.5000 NIA
Telephone
Fax
919.600.1163
Mobile Phone
[e-mail]
Email Address
Area Disturbed: 85 acres
3702600 ft2
Length of Streets: 0 _
linear feet
Length of Sewer Line: 0
linear feet
Length of Stormwater: 3131
linear feet
# Stormwater BMPs > 5 acres -
Longitude:
Panel #: 0628
-78.8735
Effective Date: 02 May 2006
Total Post Development Impervious Surface: No permanent impervious Ft2
10. Approximate Date Land Disturbance Will Begin: October 2021
11. Signat and Witness: The above information is true and correct to the best of my knowledge and
belief a wa pr me while under oath.
Signature �APerso irWncially Responsible Type or Print Name Legibly
Title or Authdrity Date
I, t a Notary Public of the County of e hereby certify
that J Z �� personally before me this day and under oath acknowledged that
this Application for Construction Drawing Plan Approval and Erosion & Sedimentation Control Plan Approval/Land
Disturbance Permit Statement of Ownership and Financial Responsibility was executed by him or her.
Witn ss my hand and notarial seal, this rA day of �� 20
Sig ture of Notary Public MyllCommission Expires
SEAL
Notary Public y�
wake ?
County
My C m I. Exp. ~`
90o I %20 t 3
5-2.14 o\,���`��
CAR
FOR OFFICE USE ONLY
Date Completeness Verified:
Project Number: PN-
Fees Paid:
❑ Construction Drawing Review Fees
❑ Erosion & Sedimentation Control
Plan Review Fees