NCC230174_FRO Submitted_20230124

WAKE COUNTY FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
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
N„r 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 Arendell Ave
2. Location of land -disturbing activity: Jurisdiction
Highway/Street Arendell Ave Latitude
Town of Zebulon
35.828478
3. Approximate date land -disturbing activity will commence:
(Wake Co. or Municipality)
Longitude -78.316917
4. Type of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site utilities and borrowlwaste
areas): 1.37 AC
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason W.-ounter E-mail Address ][e-mail]
Telephone Cell # 919. 6 4 5.8287 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
Wellspring Carolina Investments LLC
Name(s) Telephone Fax or E-mail address
2649 Brekonridge Centre Dr Ste 104 2649 Brekonridge Centre Dr Ste 104
Current Mailing Address Current Street Address
Monroe
City
8. Deed Book No. 018279
Part B.
NC 28110-5632 Monroe
State Zip City
Page No. 00189
NC 28110-5632
State Zip
Provide a copy of the most current deed.
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):
Wellspring Carolina Investments LLC
Name
E-mail Address
2649 Brekonridge Centre Or Ste 104 2649 Brekonridge Centre Dr Ste 104
Current Mailing Address Current Street Address
Monroe
City
NC 28110-5632 Monroe NC 28110-5632
State Zip City State Zip
Telephone Fax Number

L. (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:
Jason W. Counter
Name
301 Fairfax Lane
Current Mailing Address
Cary NC 27513
City
Telephone
[e-mail]
E-mail Address
Current Street Address
State Zip City State Zip
919-645-8287 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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State
Fax Number
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
corre{c,te/dam information should there be any change in the information provided herein.
�RECIIS�blf�s} �CA-Y3�ii1^C4 �i-dtVC'�Y�l�Y4'�
Type or print name Title or Authority
Signature T Date
a Notary Public of the County of UyLtolll_
State of North Carolina, hereby certify that r�L,C 41 Q!Lf0e— appeared
personally before me this day and being duly sworn acknowledged tat the above form was executed by him.
Witness my hand and notarial seal, this I day of 20 7
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Notary
My commission expires