NCC220320_FRO Submitted_20220114

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 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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name DU,,Kc.,yo ny,4-V Yt0yvit
2. Location of land -disturbing activity: County (VU %-�1Nfrv'I City or Township PU eyL&P ,
Highway/StreetdA32 BrCAJ Sf Latitude 3(0 • OUVI Longitude • �� q %
3. Approximate date land -disturbing activity will commence: I F 1'7 Z"y Z,-?-
4. Purpose of development (residential, commercial, industrial, institutional, etc.): CO m.n^t'rc1,0,
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): S' • (0�
6. Amount of fee enclosed: $ (00 0 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes �/ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name C� FOW I � ✓1 q E-mail Address 6�-&d l�^' b� ZC�v� Gt►-t&h-vc�i Ovt,
Telephone N.1 Cell # q ( q '-' 74Y-- V4$ax # �n
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Vyv't'1,ctv✓t Cdv�q N 9 l 9 - Vao - 0 a40 N_� A _
Name Telephone Fax Number
Current Mailing Address Current Street Address
PL)0i& m NC a.77o� P -k&wi ,N C .9-"77a�
City State Zip City State Zip
�tt c^/ 0
10. Deed Book No. t l 'f Page No. 34 a 35 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
!`�rG�G�tUK C�miryc4 o,, Oo. b @6o'-dtewXwvxs1yyC+TaV't, CoKn
Name E-mail Address
II SE) &1� N4W4-[V% S@ree+ lot l 3S ew / &V-tf►, vim, - # ! o
Current Mailing Address Current Street Address
R&Iygu 1�fc' Qfc, a7(901 —/918
City U State Zip City State Zip

Telephone 9 ( 9 — 74484I S Fax Number N / 4
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of
the designated North Carolina Agent:
N(Pt
Name
NL
Current Mailing Address
/'jlA
City State Zip
Telephone N /A
jVrA
E-mail Address
NL
Current Street Address
1\11A
City State Zip
Fax Number N1 A
(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:
y 1A-
Name of Registered Agent
N14
Current Mailing Address
City State
Telephone_ N
E-mail Address
Current Street Address
N A
Zip City State Zip
Fax Number N//4
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.
Cara & R o I-) I ,'I
Type or print name
Signature
I9ro:�CA' AmCA,
Title or Authority
(r �1_ 710 217,-
Date
a Notary Public of the County of
State of North Carolina, hereby certify that i! i appeared
personally before me this day and being duly sworn acknowledged thatAhe above form was executed
by him. yy �(� ` j�
"t t llt , 20
Witness my�.k►�1ijI'�N jigptarial seal, this A�day of t
!Votary Public
Johnston - Notary
� SeaNnry
®�i��'' \\ My commission expires

prepared by Lester W. Owen, County Attorney
Mail to P.o. Box 810, Dhm, N. C. 27702
Yw
kr;r 1147! 348
NORTH CAROLINA
DURHAM COUNTY
DEED
THIS DEED, made and entered into this 16th day.of November ,
1983 by and between Central Medical Associates, a North Carolina General Partnership,
Grantor, and Durham County, Grantee;
WITNESSETH:
That Grantor, for and in consideration of the sum of One Dollar ($1.00) to
it'in hand paid, 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 of that certain lot or parcel of land situated in the'City of Durham, -
Durham Township, Durham County, North Carolina, more particularly
described as follows:
"BEGINNING at a point located where the eastern right of•way, of North
Broad Street intersects the center of Elerbee Creek said center of the
creek being located North 280 26' 32" East 20 feet.from a stake in the
eastern right of way of North Broad Street, said stake being located
North 280 26' 32" East 42.4,0 from the intersection of the eastern
right of way of North Broad Street with the center line of the Duke
Power transmission line; running thence from said point of BEGINNING
along and with the center of Elerbee Creek as it meanders in an easterly
direction for a distance measured by a traverse line which has its
starting point at an iron stake which is South 28° 26' 32" west 20
feet from the intersection of the center of Elberbee Creek and the
eastern right of way of North Broad Street; said traverse line having
the following courses and distances: South 540 47' East 153.12 feet to
a stake, South 80' 09' 36" East 161.89 feet, North 860 59' 26" East
131.46 feet to the terminus point of the traverse line, said terminus
point being located South 071 32' 551' West 8.88 feet from the center .
line of Elerbee Creek; running thence from said point in the center
line of Elerbee Creek South 070 32' 55" West 318.36 feet to an iron
pipe; running thence South 880 38' 45" West 223.45 feet to an axle;
running thence North 500 06. 43" West 333.37 feet to an iron pipe
located in the eastern right of way of North Broad Street; running
thence along and with the eastern right of way of said.street as it
curves in a clockwise direction said curve having a radius of 1,391.17
feet an arc distance of 157.70 feet to an iron stake; thence continuing
with the eastern right of way of said street North 28° 26' 32" East
98.56 feet to the center line of Elerbee Creek being the point and
place of BEGINNING and being all of Tract 2 containing 3.21 acres,
more or less, as shown on that plat and survey entitled "Survey for
County of Durham" as prepared by George C. Love, Registered Land
Surveyor, dated 9-14-83, Job #14131-83C and recorded in Plat
Book t()4 at page _90_, Durham County Registry; to said plat and
survey reference is hereby made for a more particular description of
same,
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.
t.
E

LJ
C
I BOOK 1147pm 349
I 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, and that
title is marketable.
i
IN WITNESS WHEREOF, the Grantor has caused this instrument to be signed in
its name by its duly authorized general partners by authority granted to the
general partners executing this deed, the day and year first written above.
CENTRAL MEDICAL ASSOCIATES
• Gay � �
By:
General Partner
I By:
I= L'O
General P rtner
t
NO TH CAROLINA
COUNTY
C
a Notary Public of the county and state aforesaid, certify that
1 . ,� �,- ,/, n1 d personally came before me this day and
acknowl;ed1.g�d-that he is a general partner of Central Medical Associates, a North
CArbliiia general partnership, and that'by authority duly given and as the act of,
tcrs:-gftne'rship,' -the foregoing instrument was signed in its name by him,
L IIAppF
WITt 'S 6y hand and official stamp or seal this the / „ day of
1'?• .', , 1983.
A U d L\ C `u•,; Notary Pu c
�fY.'/Cemmi-4�i*txpires: •
CAROLINA
(..r ,,, COUNTY
I, a Notary Public of the county and state aforesaid, certify that
l �� personally came before me this day and
ck anowledged that he is a ge eral partner of Central Medical Associates, a North
Carolina general partnership, and that by authority duly given and as the act of
the'"PtkeTship; the foregoing instrument was signed in its name by him,
WV'rN9SS my -hand and official stamp or seal this the /1.t1., day of
,�'•__�lf1u4i+,°k�;t.i , 1983.
tj0TA, I? ,
e, Notary Public
c, M9 j ftaf�M ton expires :
141 ca'
-2-

� A
im U47 PACE 350
;
The foregoing
Certificate(s) of
are
is/a*e hereby
certified to be correc�is
i 4 ument and this certificate
duly registered
at the date and
-time and in the Book and Page 'shown on the first
page hereof.
;
RUTH G.GARRETT
REGISTER OF DEEDS FOR DURHAM COUNTY
By.
Deputy/Aoei-e4oAt-Register of Deeds
FILED
BOOK aZP,lcrr y - sr-b
F�6 Ir 2 is '8q
RUTH C. GARf<ETT
REGISTER OF DEEDS
DURHAM COUNTY, NC
i
I ,
1
de:238/A t.