NCC223509_FRO Submitted_20221011

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
WAKINo person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County 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
NOR III( AWl INA 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 Wako"ed Wendell Stand Alone Emergency Department
2. Location of land -disturbing activity: Jurisdiction Wendell (Wake Co. or Municipality)
Highway/Street Wendell Valley Blvd Latitude 35°47'00.1 "N Longitude 78025'59.9"W
3. Approximate date land -disturbing activity will commence: October 1, 2022
4. Type of development (residential, commercial, industrial, institutional, etc.): InStitutional
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas): 5.80
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name r1l'i Ad Lo.V't' rJ p� E-mail Address .Lf1,��,✓ yYh
Telephone ` ��� Cell #
Fax #
7, Landowner(s) of Record (attach accompanied page to list additional owners):
NAKtIp c,i l I�rtr pL, CgfVt c ca Of ll 9 DZ1 Y
Name(s) ��'��..." Telephone
ID a 0 Nor
Current Mailing Address
'h1C-t G
City State Zip
Sh*X,
Current Street Address
tarty
Deed Book No. 017657 Page No. 01728
Part B.
State
Fax or E-mail address
Zip
Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
com rehensive list of all responsible parties on an atta hed sheet. Include requested information):
Name E-mail Address
Current Mailing Address +L.IGtpCurrent Street Address
L 27
16 a
City U
D1� Q State Zip City
Telephone 4t- 1 3SP bQ 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:
Name of Registered Agent E-mail Address
Current Mailing Address
City State
Telephone
Current Street Address
Zip City
Fax Number
State Zip
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.
pe or print ame Title or Authority
natureA I III��
Date
+4 k- + l_L_0 a Notary Public of the County of W A kE
State of North Carolina, hereby certify that �T+-it]H a. GAV 0Kj fl
EF
personally before me this day and being duly sworn acknowledged that the above form was appeared
executed by him.
Witness my hand and notarial seal, this jr"
Z _day of L— �, 20__ 2
4
MAWL CUBIILLOS otary
NOTARY PUBLIC My commission expires � !(a 2
WAKE COUNTY, NC