NCC223787_FRO Submitted_20221109

No person may initiate any land-disturting activity on one or more acres as covered by the
be of 5 0 rJ a of Knightdale Unified Development Ordinance IF e thi f rm a d an ccePpta,
erosion and sedimentation control plan have been completed and approved by Town
Knightdale, Public Wori(.s Department. Stormweter Dmision, (Please type or print and, if III
question is not applicable, place NJA in the blank,)
7:art A.
1. Project Name Wake Veterinary HospltZ,
2. Location of land -disturbing activity: Town Limits (Town Limits or ETJ)
Highway/Street Tandal Place Latitude 35*47'35.8"N Longitude 78"30'36.5"W
I Approximate date land -disturbing activity will commence:
4. Type of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site utilities and borrowlwaste
areas;. 1A
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity. -
Name Brian - Wood E-mail Address [e-mail]
Phone # Cell # 252-258-6588
7, Landowner(s) of Record (attach accompanied page to list additional niAmv.-m.
Rowdy Ridgebaci&,-Holdings t, t, C, dmiri@thevetspets.
Telephone E-mail address
4935 Raleigh Rd Pkwy 1007 Tandal P1
6. nt Mailing Address Current Street Address
Wilson NC 11715% Knightdale NC 127,
C.
ity State Zip pity . . .................. .. .. .
y State Zip
& Deed Book No. 17298 Page No. 2413 Provide a copy of the most current deed -
Part B.
I 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):
%wd,l Kd5ebc�c le5 Ko1d%&Y%qs, L.L.C. [e-mail]
Name �J E-mail Address
4935 Raleigh Rd Pkwy 2500 Medway Drive
Current Mailing Address
Wilson NC 279%
city State Zip
Phone # [phone]
Current Street Address
Raleigh NC 27608
City 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 Town of Knightdale Erosion and Sedimentation Control Ordinance andfor
z Land Disturbance Permit-,
George Ghneim [e-mail]
.11 ... . ...... .
Name E-mail Address
1007 Tandal PI
Current Mailing Address
Knightdale NC
city state Zip
Phone # [phone]
Current Mailing Address
Ci
ty State zip
Phone #
1007 Tandal PI
Current Street Address
-Knightdale NC 27545
City St P
Zip
0 SEMI, 4
Current Street Address
M
state zip
MARI Raw_ w- wiw&�714=11-7* QN1 WOR
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
George Ghneim
Type or print name Title or Authority
Signaturt— Date
of the County of 6�zlz_s O'n
State of North Carolina, hereby certify that C- appeared
personally before me this day and beinq duty sworn acknowledged that the above fwrm was executed bv hitc.
i4l
Witness my hand and notarial seal, this —SLO day of
Notary
My commission expires
J